Dental Sleep Practice - Fall 2016

How Airway Management’s

TAP

Sleep Care System Continues to Revolutionize SDB

Which Class?

Choosing Education Wisely

by Barb Jacobucci, MEd

PLUS

FALL 2016

Knowledge is Power

Hold on to those Reimbursements

by Rose Nierman, RDH

5 Things Top DSM Practices Do Supporting Dentists Through PRACTICAL Sleep Apnea Education

by Autumn Bodily, RDA

The Industry’s Leading

Home Sleep Testing Provider Serving Medical & Dental Communities

Customized prescription for your practice Simplified apnea risk screening questionnaire Enhanced prompt reports with multi-night comparisons Board-certified sleep physicians in all 50 states Advanced sleep products for trial & co-therapy, like Apnea Guard Trial Appliance & Night Shift Sleep Positioner

Contact us at: 888-240-7735 or visit ezsleeptest.com Night Shift & Apnea Guard, designed and manufactured by: Advanced Brain Monitoring, Inc. www.AdvancedBrainMonitoring.com U.S. and Intl Patents and Patents Pending

INTRODUCTION

Narrowing the Gap

D

entists have been told since the first day of graduate school that learning is life-long, that their dental degree is only the beginning, and that keeping up with what is known is part of the professional’s commitment. Sleep medicine, which has come to be understood only within the current generation of medical doctors, researchers, teachers, and dentists, is especially challenging as the volume of ‘what is known’ is constantly, and rapidly, expanding.

Pankey Institute training used to emphasize ‘Narrowing the Gap Between What is Known and What is Practiced.’ I’ve always liked this phrase because it illustrates nicely the challenge we all willingly and, to varying degrees, enthusiastically, embrace. Facing our patients daily with the awesome responsibility of tailoring scientific knowledge to their clinical presentation and finding solutions for critical medical, social, and behavioral needs demands that we keep up with what is known and apply that to our work to narrow the gap.

It’s not enough to just go to class, to only read the journals, to confine yourself to increasing your treasure trove of details about medical practice. Education requires implementation to have value.

Fortunately, as soon as you start identifying sleepy patients in your practice or telling your colleagues that you’ve discovered an exciting new way to serve, you will be presented opportunities to use this knowledge. Your staff will look at you in the team meeting, confident that their leader will help them navigate new systems, new conversations, new job skills. Your patients will ask you about the importance of the 6 they just scored on the STOP-BANG or the 14 on the Epworth your hygienist handed them in your fresh screening protocol.

They’ll bring in a sleep study to their next visit and ask you what it means, now that you’re a declared ‘expert’ – because they trust you more than they do the sleep doc they just met.

Ready for that? Some of you are gleefully embracing these opportunities, eagerly seeking the rewards that accompany solv-

ing clinical riddles posed by our patients and moving them along the path towards better health and happier social life. Others of you are stuck in the learning loop, overly impressed by ‘how much there is to know’ before beginning to provide solutions to your patients.

The gap is real. One side, what is known, is moving all the time – very rapidly in sleep medicine. Knowing more is not like piling books on a chair so eventually the cookie jar becomes within reach. The gap between what you know and what you put into practice can only be narrowed by action.

Apply your knowledge. Put into play something you learn from this issue of DSP, as soon as you read it. Talk to a team member about an idea, solicit one from them, and make something happen. After it’s done, talk about it some more – think about the process, the outcome, the reward, the lesson learned. What you’ll do next time the same opportunity comes your way.

Repeat the process for another idea, something you learned or a conversation with a medical colleague. Involve your team and watch how they blossom in this exciting atmosphere of leadership, collaboration, and reward.

You’ll create a culture of narrowing the gap. Can you close it? No chance – that bank of knowledge is growing faster than you can keep up with and the individuality of our patients means no one ever precisely matches the case example. Our medical decision-making is the action that narrows the gap – forming bridges to the other side.

Making a difference. That’s the life of a professional. And it is spectacular.

Steve Carstensen, DDS Diplomate, American Board of Dental Sleep Medicine

Thomas Meade, DDS

DSP is sad to hear of the passing of Dr. Thomas Meade, one of oral appliance therapy’s pioneers. It was an honor to profile Dr. Meade in the Winter 2015 edition. Our deepest sympathies to Dr. Meade’s family and the many friends he made over decades in service to his profession.

DentalSleepPractice.com

1

CONTENTS

8

Cover Story

How Airway Management’s TAP Sleep Care System Continues to Revolutionize SDB

by Keith Thornton, DDS Address every clinical need with a custom solution.

6

Education Format

Which Class?

Choosing Education Wisely

by Barb Jacobucci, MEd Organize your thoughts to maximize your benefits.

40

Nutrition

Helping Sleep Patients Understand How to Lose Weight

32

by Dr. Warren Schlott Understanding nutrition and metabolism can help you counsel patients well.

Practice Management

Knowledge is Power Hold on to those Reimbursements

by Rose Nierman, RDH Another case of doing it right reaping rewards.

48

Practice Management

5 Things Top DSM Practices Do

by Autumn Bodily, RDA Great material for your next team meeting.

2 DSP | Fall 2016

63

LinkedIn

Verbal Skills that Help Build a DSM Practice

by John Viviano, DDS, DABDSM First part of a regular feature.

Introducing a new generation of oral appliance therapy.

2.5x

7 DAY

Faster Treatment

Turnaround Time

FASTER

3x faster than leading competitors*

HEALTHIER

Unique metal free titration with 3.6x less monomers*

EFFICIENT

Titration requires fewer steps and appointments†

COMFORTABLE 30% less overall volume*

MicrO2® Sleep and Snore Device by ProSomnus™ Sleep Technologies, a new way to help OSA patients wake up refreshed and energized.

Join the growing number of dentists and patients who are benefiting from MicrO2. Visit ProSomnus.com or call 844.537.5337 for a free starter kit.

PRO_1606132_V8

1-844-53SLEEP ProSomnus.com Micro2sleepdevice.com *Data on File. †Based on a comparison of a meta-analysis, “Is Selecting the Appropriate Sleep Device for You and Your Patient Important?” by Dr. David Carlton III, and New Oral Appliance Titration Protocol using MicrO2 and Mandibular Positioning Home Sleep Test. Presented at AADSM on June 10, 2016 by Dr. Remmers 1,2 and Dr. Vranjes3 during poster and oral presentations. 1University of Calgary in Alberta Canada, 2Zephyr Sleep Technologies, Calgary, Alberta, Canada, 3The Snore Center, Calgary, Alberta, Canada.

CONTENTS

13 Financial Focus

Is your retirement plan strategy due for an annual checkup?

by Tom Zgainer Understand the benefits of reviewing your 401(k) plan on a regular basis.

14

Physiology

Expanding Airway Education

by Jeffrey Hindin, DDS Measuring more than airflow helps patient assessment.

16

Clinician Spotlight

New Center for Pain and Sleep Opens in Dallas Advanced dental sleep education finds another home.

22

Manufacturer’s Comments

More than Jaw Positioning

36

Team Focus

Patient Education! The single most important topic.

by Glennine Varga, AAS, RDA, CTA Your team knows, but the patient has to learn, too.

38

Organization Spotlight

Learning Sleep from AADSM An interview with Harold A. Smith, DDS, president of the AADSM An unbiased source is always good to keep in mind.

45

Product Spotlight

eyeCAD-connect®, the Heads-up Display for digital dentistry

by Sven Holtorf, DDS Here’s something you’ve probably not thought of!

52

Your Sleep Ambassador is the Difference

26

by Dr. Gy Yatros The right person is key to a successful sleep practice.

Is your website really working?

by Ian McNickle, MBA How to convert website visitors into new patients.

28

Meaningful Conversation

54

Clinical Focus

Maxillofacial-Mandibular Advancement and Oral Appliance Therapy

Post Graduate Education is the Key

by Clark O. Taylor, MD, DDS The surgery option is best introduced early.

by Mayoor Patel, DDS, MS There are many choices. Find the right one for your team.

56

34

by Ken Berley DDS, JD, DABDSM Answers to common questions by our legal expert.

Technology Update

Digitization of Dental Sleep Medicine

by Tarun Agarwal, DDS, PA Help your ROI with technology.

4 DSP | Fall 2016

Legal Ledger

Short Stuff

64

Publisher | Lisa Moler lmoler@medmarkaz.com Editor in Chief | Steve Carstensen, DDS stevec@medmarkaz.com Managing Editor | Lou Shuman, DMD, CAGS lou@medmarkaz.com Editorial Advisors Steve Bender, DDS Ken Berley, DDS, JD Ofer Jacobowitz, MD Christina LaJoie Steve Lamberg, DDS, DABDSM Dale Miles, DDS Amy Morgan John Remmers, MD Rob Rogers, DMD Sarah Shoaf, DDS, MSD Bruce Templeton, DDS, MS Jason Tierney Glennine Varga, AAS, RDA, CTA

Practice Management

by Dr. Mark E. Abramson Think beyond advancement.

Practice Development

Fall 2016

Sleep Deeply Wake Refreshed

DSP Crossword

General Manager Alan Lobock | alobock@medmarkaz.com National Account Manager Donna Aly | daly@medmarkaz.com Manager – Client Services/Sales Support Adrienne Good | agood@medmarkaz.com Creative Director/Production Manager Amanda Culver | amanda@medmarkaz.com Website Manager Anne Watson-Barber | anne@medmarkaz.com E-media Project Coordinator Michelle Kang | michellekang@medmarkaz.com Front Office Manager Theresa Jones | tjones@medmarkaz.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.DentalSleepPractice.com Subscription Rates 1 year (4 issues) $99 | 3 years (12 issues) $219 ©MedMark, LLC 2016. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Dental Sleep Practice magazine or the publisher.

EDUCATIONformat

Which Class?

Choosing Education Wisely

by Barb Jacobucci, M.Ed

J

ohn has been your patient for five years. He has mentioned his snoring problem to you on previous visits. “Doctor, my snoring has gotten so bad lately and it is really disrupting a peaceful night’s sleep in my house. My wife said that it is time to do something about it. I’ve done some research and read about an oral appliance. Can you help me?”

The next question is potentially the most important. It always starts with “Why?”

This isn’t the first time a patient has wanted to have this conversation with you. You have been hearing comments amongst your colleagues, your staff is talking about it and you are reading about it in trade publications. You have decided that now is the time to educate yourself and provide a solution for your patients.

Once you have made the decision to pursue a new educational experience, where do you start? Who is the authority? Where do you find a quality educational experience? Will the experience match your style and meet your needs? The questions can be overwhelming.

Growing your practice is top of mind for you every day. Making the decision to add new learning can be a challenge in time and commitment. As you contemplate educational choices for this or any other need in your practice, there are questions you can ask to find the educational resource with the solution that best fits into your practice.

1. Why?

The first question you should ask yourself is whether the professional and educational development that you are considering aligns with your practice mission and goals,

6 DSP | Fall 2016

and does it improve your patient care. If the answer is yes, the next question is potentially the most important. It always starts with “Why?” If you want a treatment, product, or service to succeed in your practice, it is important to start with asking “Why?” Why do your patients want or need this treatment?

What is their emotional motivator? What is their desired outcome? Your patients will take action based more on their emotional needs than on a detailed reasonable statement of the treatment benefits. With a solid “Why”, you are ready to proceed.

2. Educational Outcome

Now that you have clarified your why and established the need, define the educational and learning outcome that you wish to achieve. Is this your first step in educating yourself on a topic? Perhaps you are ready to complete a learning experience that prepares you to introduce a new method to your team, immediately implementing it into your practice.

3. Research and Reviews

You have many resources available to you to support making your educational decisions. You are holding (or viewing online) a powerful resource in Dental Sleep Practice magazine. This magazine and other professional resources are treasure chests of valuable information. These resources provide you with current information, keep you upto-date on the latest information, and expose you to like-minded professionals and peers.

Reach out to your peers, staff, consultants, study groups, and online forums for

EDUCATIONformat references and recommendations. Past experience with their chosen instructional methods can help you in making decisions based on the elements that are important to you.

Review how they measured the results, the quality of their educational experience and their outcome.

Don’t forget to review your past educational experiences and resources. Do any of these resources provide you with the additional education and information that you are seeking?

Evaluate and review your resources. Do you have the time and dollars to commit to bringing the educational results to your practice? Does the cost associated seem reasonable given the benefit you will receive (remember your Why)?

4. Instructional Method

Evaluate your educational options, and determine your most effective learning environment and personal preference. Do you excel in hands-on workshops with active involvement from the participants? Do you prefer seminars or lectures? Consider e-learning, webinars or distance learning options, if available. Also review the educational options available from your professional associations and conferences.

Other considerations for choosing an instructional method are: • Cost of the program and evaluating what is included. It is important to consider the amount of time away from your practice, your study time, travel time and if any members of your staff will be attending.

• If there are multiple sessions, how often do they meet and what is the typical length of each?

• What is the format of the training? Is it geared toward a small group, large group or individual instruction?

• Does the training include demonstrations, theory, and practice? Will you be conducting hands-on exercises to enhance the learning experience? Are new technologies applied that will assist in your learning experience?

• Is the training conducted on-site or off-site?

• Are the learning outcomes clearly stated? Do they indicate specifically what you will be able to do as a result

of the program? This element will help you determine if the educational offering is a broad overview course or an in-depth program.

• Determine if the educational offering meets the need as established in your Educational Outcome review (Step 2).

5. Instructors Credentials

If you have chosen a structured class environment, review the instructor’s credentials. Instructors take an active part in your learning experience so you are relying on their skills as an expert and a professional.

Is the subject matter an area of expertise for the instructor? Is the instructor a trusted resource and informed professional? Do their qualifications indicate that a meaningful program and instructional experience will be delivered?

6. Follow-up, Implementation and Instructor Support

Another important consideration is how quickly you will be able to implement the new skills into your practice. Will you be provided with the materials, support and guidance on how to effectively bring the new skills back to your office? Will support be available for implementation beyond the initial training?

Determine what learning community you will receive from the educational experience. From collective learning and community support, will you leave with a wider personal learning network?

And finally, revert back to Step 1. Not only does it start with why…it ends with why. As you are participating in your educational experience, remember your Why and your patients Why. During John’s next visit, you will be able to say “YES, John, I can help you!”

Follow these steps and you will walk away from your educational experience saying “That was a great choice!”

Another important consideration is how quickly you will be able to implement the new skills into your practice.

Barb Jacobucci, M.Ed, has spent her career in training, development and motivation. As an experienced entrepreneur and business leader, she understands the important connection between marketing, training, sales and patient care. With a focus on the patient experience, Barb provides insight and training on the communication skills critical to reach practice goals and objectives. Barb can be reached at barb@jacobucciconsulting.com.

DentalSleepPractice.com

7

COVERstory

How Airway Management’s

TAP Sleep Care System

Continues to Revolutionize SDB

I

n 1992, an ENT surgeon referred a patient diagnosed with Sleep Related Breathing Disordered (SRBD) to me. This patient was non adherent with CPAP at a pressure of 18. Her sleep physician stated that since she had “failed CPAP” and was not a surgical candidate, her only option was to go to “this dentist who might have a solution”. Within a week, she received the only device available at the time, a Tongue Retaining Device (TRD). She died two weeks later in her sleep of cardiac arrest.

8 DSP | Fall 2016

COVERstory Several lessons were learned from this: • CPAP failures were common, even among the most severe patients treated by the most expert specialists.

• Dentists had the education and skills to treat this problem but needed better tools.

• The problem was a mechanical collapse of the pharynx which could be treated by the same principals used in cardiopulmonary resuscitation and anesthesia by “airway management”.

This began my quest to develop devices that would manage all levels of SRBD from mild snoring to severe obstructive sleep apnea syndrome. Airway Management’s story begins in 1994, when I built my first adjustable mandibular advancement device to treat obstructive sleep apnea. I had been very successful in my own clinical trials and decided to share the device with other dentists and physicians that were looking for an effective OSA treatment that patients would actually use every night.

By 1996, I obtained the necessary patents and regulatory clearance to market the device to professionals. The TAP 1 was launched and quickly adopted by the pioneering dentists in the fledgling dental sleep medicine market. It was the first adjustable device that was easy to titrate, comfortable and immediately effective for OSA patients.

The overwhelmingly positive response from the DSM dentists made the TAP 1 a huge success thus changing the course of my professional career. I was able to turn an interest in airway management into a mission to improve the lives of patients with SRDB. Over the next 20 years, I worked to constantly improve on the design of the appliance, and in May 2016, we introduced the 5th generation custom appliance, the dreamTAP. I opened both Airway Labs to fabricate the appliances and act as my research and development department; and Airway Management to distribute to and support other dental laboratories and professionals worldwide. My philosophy has been to share the technology with those dental laboratories who want to offer our products which in turn has allowed us greater exposure and availability.

Today, Airway Management (AM) offers a robust product line that includes immediate delivery devices (myTAP), custom mandibu-

lar advancement devices (dreamTAP), CPAP masks (myTAP PAP) and combination therapy (TAP PAP CS). From predictor appliance to custom solutions, the TAP System has a range of advanced devices covering the full spectrum of SRDB.

Design Principles

When I began to develop the TAP in 1994, I established three core design principles for the appliances that have guided all subsequent products; simple, durable, & patient friendly. These concepts are the foundation for every custom TAP appliance.

• Simple: Single point adjustment and custom fit trays • Durable: Metal injection molded hardware with the finest dental alloys and high strength dental grade plastic trays.

• Patient Friendly: Easy to use and lowrisk advancement mechanism Over the years, the TAP appliances have been the subject of over 36 independent peer reviewed studies, the most of any other appliance. The studies proved that the custom TAP appliances consistently held up to CPAP and surpassed other mandibular advancement devices. After twenty years of studies, the conclusion is, it works.

AMI is very proud to supply the TAP System to every branch of the US Armed Services The academic studies are excellent to prove the design principles but market acceptance by large organizations are another indication of the value of the TAP design in treating OSA. Airway Management is very proud to supply the TAP System to every branch of the US Armed Services, including the Veterans Administration, to ensure our service men and women are getting the best treatment wherever they are in the world. In addition, several of the most successful dental laboratories, in the USA and globally, manufacture TAP appliances for their clinicians.

DentalSleepPractice.com

9

COVERstory TAP Sleep Care System

myTAP The TAP System begins with the myTAP trial appliance (Figure 2). The myTAP allows the prescriber to provide same day treatment and immediate relief for their patients. The myTAP boasts the same midline advancement technology as the proven custom TAPs with an immense 21 mm range of advancement. This technology allows the prescriber to truly test the patient’s outcomes, compliance and acceptance of an oral appliance prior to prescribing a custom appliance.

TAP custom The core product line in the TAP System is the custom TAP appliances, beginning in 1994 with the TAP 1. Since then, custom TAP has evolved into many versions for all types of patients and levels of SRDB including the TAP 3, TAP 3 Elite, and the most recent and all new dreamTAP. dreamTAP dreamTAP (Figure 3) is the 5th generation of the custom TAP appliance. After years of R&D, the dreamTAP was released in May 2016. For the casual observer, it looks similar to the previous versions of the TAP, but for the dentists treating OSA patients, it is a significant improvement.

The core TAP design principles are clearly displayed in the dreamTAP including the single point adjustment, ease of use for patients and practitioners and the durable, custom trays.

The most significant and obvious design change is the placement of the hardware.

The hardware has been flipped placing the advancement mechanism on the mandible and the bars on the maxilla. All the hardware is facial to anterior teeth to maximize tongue space.

The durability has increased with the introduction of Chromium-Cobalt (Cr-Co) hardware. The advancement mechanism and hooks were redesigned before being tested for strength and tolerances as the design was fine tuned.

The dreamTAP is a very flexible treatment tool. Dimensionally, the lateral excursion in the anterior can be fabricated from about 4mm to 15mm. Airway Labs standard lateral excursion is approximately 15mm. The vertical height between the trays has been reduced

10 DSP | Fall 2016

myTAPTM

TAP CUSTOM

myTAP PAP

TAP PAP™ CS

Figure 1: TAP system

Figure 2: myTAP

Figure 4: Close up of hook

Figure 5: Long/medium/short hook

Figure 3: dreamTAP

to about 5mm. The clinician can prescribe the appliance with up to 15mm of vertical opening as determined by his/her preference.

One of the biggest advantages of the dreamTAP is the vast 15mm of horizontal protrusive range. The screw mechanism has a range of 5mm (Figure 4). You can extend this range with three hooks included with every appliance (Figures 5-6).

The bottom line is that the dreamTAP has the largest range of any oral appliance to treat OSA and SRDB. The dreamTAP is NOT technique sensitive. It is very flexible to ensure that wherever your starting position is, the dreamTAP can be adjusted in the practice to fit the patient’s needs.

Medicare vs Quick Release

Figure 6: Protrusion Range

Figure 7: Medicare Release point

Like all the of the custom TAP appliances, dreamTAP has received approval by PDAC (Pricing, Data, Analysis and Coding) and is accepted for reimbursement by Medicare.

The dreamTAP meets the requirements of PDAC by creating a hook design that is hinged and cannot be easily unhinged by the user. We use a 1.3mm bar to create the hinge with the hook. You must engage the hook on the side of the bar, where the diameter is reduced to accept the 1mm opening in the hook (Figure 7).

During R&D and patient testing, it became apparent there was a need to create an optional version that allowed the patients to quickly unhook while wearing the appliance.

The “Quick Release” optional bar design was created to allow for this. The Quick Release version can be used with any insurance carrier not requiring PDAC listing for coverage.

Quick Release dreamTAP uses a 0.8mm Cr-Co bar to engage the hook. The patient simply advances the mandible about 1.5mm

MORE COMFORT.

MORE INNOVATION. MORE TONGUE SPACE.

dreamTAP FROM TAP SLEEP CARE

To learn more about dreamTAP and the TAP System, register for our FREE Webinar at bit.ly/TAPwebinar or email contactami@amisleep.com for more information. myTAPTM

TAP CUSTOM

myTAP PAP

TAP PAPâ„¢ CS

COVERstory to release the hook, while wearing the appliance. This eliminates any concerns about being “locked” in and makes it easier to insert and remove.

Options

Figure 8: TAP PAP CS

Compliance tracking on custom TAP appliances is now available. We have partnered with Braebon to add the Dentitrac compliance device to our custom appliances. As insurers and government regulators attempt to increase compliance for OSA, this recording device will be extremely useful and possibly required in the future.

We will introduce a mouth shield to encourage nasal breathing, which can be added to the dreamTAP and is now available for the myTAP. Blue colored trays will be an option in the 4th quarter of 2016 as supply becomes available.

Combination Treatment

Figure 9: Demo box

Most studies have shown the TAP appliances to be very effective on their own, from simple snoring to moderate obstructive sleep apnea. To treat severe OSA, the clinician can use the TAP PAP CS, an add-on product to connect a dreamTAP (TAP 3 / TAP 3 Elite) to a nasal pillow CPAP mask (Figure 8).

This allows the professional to combine oral appliance therapy with CPAP, enabling most patients to reduce their CPAP pressures.

Many DSM dentists use the TAP PAP CS to help bridge the gap between the MD and DDS/DMD. It allows the dentist to discuss oral appliance therapy with the MD with a collaborative tangible device. Helping to create a positive working relationship be-

Many DSM dentists use the TAP PAP CS to help bridge the gap between the MD and DDS/DMD.

12 DSP | Fall 2016

tween the branches of medicine needed to treat OSA.

Grow your DSM practice

Airway Management is committed to supporting our laboratory and dental customers.

Our goal is education – the more information we can put in the hands of our customers to educate the patient, the more the patient will be fully informed about oral appliance therapy. AM offers two demonstration kits to help with just that – the dreamTAP Demo Kit and the TAP PAP CS Demo Kit. They contain both tangible demonstration models and informational brochures.

Because the majority of adults in the United States are either afflicted by or know someone afflicted by sleep disordered breathing, the normal dental practice has a large percentage of patients that need treatment. The simplest method to reach these patients is with the dreamTAP Demo Kit (Figure 9) in the waiting room. Also, a simple screening questionnaire such as the Epworth Sleepiness Scale can be given to each patient as part of their semi-annual dental visit, which can also spark conversation about TAP treatment solutions.

The TAP PAP CS Demo Kit is very effective in informing sleep physicians and medical professionals about the TAP appliance and combination therapy. Instead of simply pitting the oral appliance against the CPAP, the TAP PAP CS allows the best of both treatments, especially in a case where a patient is a CPAP intolerant or needs more therapy than CPAP alone.

Summary

Overall, TAP Sleep Care is a systematic, comprehensive approach for managing Sleep Related Breathing Disorders (SRDB).

Airway Management is extremely proud to be part of the solution; producing innovative oral appliances and other sleep therapies.

We have made tremendous inroads in the dental sleep medicine market and strive to make oral appliance therapy more readily available in collaboration with our dental, medical and laboratory customers.

If you want to learn more about the TAP system (how to order, additional options, growing your DSM practice, and more), please register for our free 1 hour webinar by going to bit.ly/TAPwebinar.

FINANCIALfocus

Is your retirement plan strategy due for an annual checkup?

R

egular maintenance regarding our health, be it a twice a year teeth cleaning or an annual physical, allows the experts to determine if we are as fit as we think we are, or see if there might be some issues under the hood that need attention. Likewise, each April, we are reminded of whether our tax planning is sufficient or perhaps needs a tuneup. Similarly, your retirement plan strategy is worth reviewing with a pension plan expert as well.

Often the original plan and strategy you implemented get away from your intended individual and corporate goals. Your employee populace may experience turnover, the actual age demographics of your staff may take on a different makeup, and by the way, you are now a year closer to retirement.

You can find these changes limit your personal contributions due to required employer contributions or, more positively, open up new opportunities to design a plan that accelerates your personal contributions.

Retirement plans — whether a 401(k), profit-sharing plan, a defined benefit, or a cash balance plan — all require some give-and-take. For owners, principals, key associates, or partners to take advantage of the opportunity to maximize annual contributions, you’ll need to give a proportional amount that passes all the required compliance tests to eligible employees.

These employer contributions at first might not be palatable to you and your bottom line. However, utilizing a long vesting schedule — for example up to 6 years — can help ensure an employee needs to stay and contribute to your practice that long to earn any 1 year’s contribution. Plus, you receive the tax deduction benefit of the full amount of employer contributions in the tax year of the contribution, up to 25% of gross payroll.

A great reason to go through an annual plan design checkup is to see if there is a better plan type option for you. As you get closer to retirement, generally over age 45, plan types, such as a new comparability profit-sharing plan, a cash balance or defined benefit plan, can be paired with a 401(k) to rapidly accelerate your personal contribution objectives.

For 2016, you can defer $18,000 into a 401(k) plan, with a $6,000 catch-up provision if over age 50. That’s generally the best first thing to try and accomplish. If your plan demographics are suitable, meaning staff is younger than the owners, principals, or partners (HCEs), and you are over age 45, a new comparability profit-sharing plan can provide a maximum benefit for a select employee group, while providing the lowest possiReceive your retirement plan checkup here: americasbest401k.com/fee-checker-medmark

ble contribution to non-key groups allowed by law. This plan design can help you add to your deferrals and get up to the $53,000/$59,000 maximum annual limits from combined employee and employer contributions.

To really accelerate your contributions, consider looking into adding a cash balance or defined benefit plan to the 401(k). Maximum contributions for these plans range from $102,000 at age 45 to $237,000 at age 62. When added to the 401(k)/profit-sharing contributions, it’s like squeezing 20 years of retirement saving into 10, not to mention the significant reduction to your tax liability that you will enjoy.

Just as you might make an appointment with your physician or CPA, this is a great time of year to get a retirement plan checkup as well. It’s easy and painless, as a census with your current firm demographics will enable a experienced pension specialist or actuary help determine if there is a better way to proceed into the years ahead for your retirement planning.

Tom Zgainer is CEO of America’s Best 401(k).

He has helped over 2,800 businesses obtain a new or improved retirement plan over the past 13 years with a focus on strategic plan design to help achieve individual and corporate objectives. You can learn more at americas best401k.com/fee-checker-medmark.

DentalSleepPractice.com

13

PHYSIOLOGY

Expanding Airway Education:

Heart Rate Variability and the Autonomic Nervous System

by Jeffrey Hindin, DDS

T

he future of dentistry lies in recognizing the dentist’s role in understanding and improving patient physiology. Monitoring and assessment of heart rate variability (HRV) and the autonomic nervous system (ANS) will be key tools to understanding the physiological basis for the inextricable relationship among dentistry, medicine and other health care practices. “HRV is a useful method to assess cardiac autonomic modulation in patients undergoing dental procedures, because knowledge of physiological conditions provides greater security to the professional as well as the possibility of a better plan treatment to patient benefit.” (M. Santana, et. al. 2013) The autonomic nervous system (ANS), composed of the sympathetic nervous and parasympathetic nervous systems, controls the cardiovascular system, in part, by releasing neurotransmitters that increase or decrease heart rate (HR), respectively. The periodic oscillations in HR and RR intervals of consecutive heartbeats, modulated by the activity of ANS on the heart is known as heart rate variability.1-5 The SNS increases heart rate and respiration rate. Increases in sympathetic outflow decrease HRV. A high HRV is a sign of health, depicting the body’s balance and shifting between sympathetic and parasympathetic pathways.

Lowered HRV is associated with disease states and poor adaptation to stress, and physiologic dysfunction.4 In dentistry, malocclusion, TMD, and surgical dental procedures have shown to lower HRV.6 Maixner et al. (2011) investigated the association between autonomic variables and temporomandibular disorder (TMD), testing the hypothesis that dysregulation In the near future, of the autonomic nervous system contribdentists will monitor utes to the onset and persistence of TMD. The authors found that patients with TMD several physiological at rest showed reduced HRV compared markers to assess the with the control group. Several articles have shown that HRV changes with jaw risks and benefits of position. Relating to sleep, patients with their treatment. OSA have lowered daytime HRV, even in the absence of hypertension, heart failure, or other disease states.7

14 DSP | Fall 2016

HindexRV® is FDA approved instrumentation to monitor HRV and the ANS and add a new level of understanding and care for patients with airway/sleep disorders. The HindexRV® system produces objective data on the physiological effects of jaw position, tooth positioning, appliance and treatment efficacy and other dental procedures.

Everything dentists do in their daily practice can influence the airway and physiology of the patient, whether the practitioner knows it or not. With HindexRV® monitoring, the clinician can objectively view patient physiology, in real time, to evaluate the efficacy of treatment modalities, e.g. appliance position, and obtain the “physiological bite”.

It is accepted that HRV is an early warning system that can provide valuable information for more optimal diagnosis and treatment. In the near future, dentists will routinely monitor their patient’s physiological functions and assess the risks and benefits of their treatment. In addition, treatment specifically aimed to promote and enhance physiological function where appropriate will be provided.

For information on HindexRV® and Physiology/HRV courses, email info@physiological dentistry.com.

1.

2.

3.

4.

5.

6.

7.

Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology: Heart rate variability: standards of measurement, physiological interpretation and clinical use. Circulation 1996, 93:1043–1065.

Valenti VE, Guida HL, Vanderlei LC, Roque AL, Ferreira LL, Ferreira C, Silva TD, Manhabusque KV, Fujimori M, Abreu LC: Relationship between cardiac autonomic regulation and auditory mechanisms: importance for growth and development. J Hum Growth Dev 2013, 2013:23.

Vanderlei FC, Rossi RC, de Souza NM, de Sá DA, Gonçalves TM, Pastre CM, Abreu LC, Valenti VE, Vanderlei LCM: Heart rate variability in healthy adolescents at rest. J Hum Growth Dev 2012, 2012(22):173–178.

Abreu LC: Heart rate variability as a functional marker of development. J Hum Growth Dev 2012, 22:279–281.

Vitor ALR, Souza NM, Lorenconi RMR, Pastre CM, Abreu LC, Valenti VE, et al: Nonlinear methods of heart rate variability analysis in diabetes. Health Med 2012, 6:2647–2653.

Ekuni D, Takeuchi N, Furuta M, Tomofuji T, Morita M: Relationship between malocclusion and heart rate variability indices in young adults: a pilot study. Methods Inf Med 2011, 50:358-363.

Narkiewicz, K. et al. Altered cardiovascular variability in obstructive sleep apnea. Circulation. 1998 Sep 15;98(11):1071-7

September 15, 2016

Airway Summit Hilton El Conquistador Resort Tucson, Arizona

For this “White Flag Event,” we’re asking you to momentarily set aside the focus on competition in the marketplace and serve patients by articulating a unified airway health message. Only 15% of airway/sleep disorders are diagnosed. Help address this major unrecognized public healthcare crisis by joining thought leaders, academies, organizations and corporations to create and bring a unified message to the public.

whiteflag@foundationforairwayhealth.org www.foundationforairwayhealth.org

CLINICIANspotlight

New Center for Pain and Sleep Opens in Dallas

16 DSP | Fall 2016

T

exas A&M University College of Dentistry has opened a new Facial Pain and Sleep Medicine center headed by Steven Bender, DDS. One of the first such centers in a dental school in the country, Dr. Bender has big ideas for how to change dentistry’s impact on whole person health. DSP recently sat down with Dr. Bender to learn more.

CLINICIANspotlight DSP: Tell me how this all got started, Steve – this is a big project.

Steven Bender, DDS: After I graduated from here in 1986, back when it was Baylor College of Dentistry, I started a general dentistry practice and stayed with it for about 13 years. One of my mentors, Dr. Henry Gremillion, then the director of the University of Florida’s Parker Mahan Center, allowed me to sort of intern with him for about two years.

I would travel regularly to Gainesville to see patients in the clinic and learn from some of the best minds in pain therapy and research.

Henry eventually told me I should ‘Pick one thing – Restorative or Pain, but knowing me the way that he did, he felt that it was best if I didn’t try to do both.’ So I sold the restorative portion of my practice and started treating only pain patients here in the Dallas area where I grew up.

For most of the 16 years since then, I was focused only on facial pain – I was aware of sleep problems, often treating insomnia and movement disorders with medications, but if there was an airway problem, I didn’t make the connection to my diagnosis and would send the airway issues to a colleague, Dr. Keith Thornton. Anyone who knows Keith also knows that he doesn’t leave you alone if he sees promise in creating another ‘sleep dentist’ so he made it clear that I needed to add treating the airway myself to my practice.

As many who read DSP magazine would guess, I started seeing much better results in my pain patients who had their airway issues treated, so that became a routine part of my therapy. What is important to know is that I think my pendulum swung a bit too far and I started seeing everyone with pain as an airway problem. Thankfully, my training from

Dr. Steven D. Bender earned his Doctorate of Dental Surgery degree from Baylor College of Dentistry in 1986 and practiced general restorative dentistry for 14 years. He then studied orofacial pain and temporomandibular disorders at the Parker E. Mahan Facial Pain Center at the University of Florida College Of Dentistry under the mentorship of Doctors Henry Gremillion and Parker Mahan. From 2000-2015, Dr. Bender maintained a private practice devoted to pain management of the head and face, as well as sleep medicine. Beginning in 2016, he transitioned to a full time faculty member of Texas A&M University College of Dentistry and assumed the role of director of facial pain and sleep medicine. He has earned Fellowship in the American Academy of Orofacial Pain, the American Headache Society, the International Academy of Oral Oncology and the American College of Dentists. He holds the office of immediate past president and current council chair of the American Academy of Orofacial Pain and is a past president of the Fourth District Dental Society of Texas and the Dallas Academy of General Dentistry. In addition, he has served as a consultant for the United States Army.

DentalSleepPractice.com

17

CLINICIANspotlight Dr. Gremillion stayed with me and I was able to improve my diagnosis so I could treat everyone appropriately.

As a teacher in this field, I get questions that make me feel that dentists aren’t always adequately trained in history-taking and can fall into the trap of seeing only airway issues (or, in the worst cases, only financial opportunities!) and not recognize other signs and symptoms as separate. All my teaching included a strong emphasis on diagnostic skills and hearing the patient’s story. I remember from years at Pankey and the Mahan Center that ‘knowing your patient’ includes much more than just the clinical signs and symptoms.

Over the course of a few years, the concept of creating a Center at Baylor began to take shape. Our Chair of Oral Surgery, Dr. David Grogan, has long been lobbying for a pain curriculum and we started talking, and Keith Thornton has been a big supporter as well. Along with the strong support of our Dean, Dr. Lawrence Wolinsky, we set up this new Center as a multi-disciplinary clinic. It opened in January this year – so far, we have limited space but hope to be able to expand soon. I was able to bring my assistant of 10 years with me, which was a huge blessing!

DSP: Please say more about what you want to do there. More than just moving your practice to another space, right?

SB: Dentists from all over will be able to come to our Center and see how we work up a patient history, make a treatment plan, and follow-through. I hope to replicate what Dr.

18 DSP | Fall 2016

Think small When we developed the first CAD/CAM oral appliance for the treatment of obstructive sleep apnea, we packed our biggest ideas into our smallest device. Today, Narval CC continues to revolutionize oral appliance therapy with its advanced technology, its proven track record of compliance and efficacy, and its compact, lightweight design. As the experts in sleep, we couldn’t be prouder to offer the very best in dental sleep.

Contact us at narval@resmed.com.

CLINICIANspotlight Our goal is for every graduate from our institution to have at the least a basic understanding of sleep and pain issues.

Gremillion did for me and offer a preceptorship for committed dentists to gain in-depth understanding of how facial pain and sleep problems intertwine and are treated. We also plan to develop mini-residency type programs in pain and sleep to give the clinician in practice an educational opportunity beyond the normal weekend type venues. Also going forward, we plan to develop a CODA approved facial pain/sleep medicine residency program, which will offer certification as well as advanced degrees.

It is exciting to be able to offer dentists who want to put all the resources into a focused practice various educational avenues to fit their needs. What I’m very excited about that might have even more impact is that I get a chance to teach undergraduate dental students about pain and sleep in their third year. Also, we hope to be able to provide a hands on experience for the students in the diagnostic and treatment planning process for their pain and sleep disorder patients. I’ll certainly be looking for the special undergraduate student or two that shows interest and aptitude to mentor like others mentored me. Our goal is for every graduate from our institution to have at the least a basic understanding of sleep and pain issues. I think that is, at best, rare in most dental school graduates today. I’ve checked with some of the leaders of other programs around the country and we are all struggling to get time in the undergraduate student curriculum. Working with the grad students is a little easier, but still a challenge.

DSP: Lucky for the Dallas community.

What else will the Center do?

SB: As someone long-committed to keeping up with the latest research and publications, I hope to be able to participate in projects here at the school that will add to the body of research involved in treating sleep and pain disorders, specifically with mandibular advancement devices, but also medically. With the resources of Texas A&M, we will

20 DSP | Fall 2016

be able to bring in our medical colleagues and create research projects that will help every clinician manage patients better. I’ve had some very exciting conversations with members of our clinical faculty, our basic scientists, faculty members of the medical school and some private practice sleep docs who all want to help create better-trained dentists.

We hope to produce a body of strong research to help the clinician in practice make the best choices for treating their pain and sleep patients. I believe that is where our center will make its mark. Keith and others here at the school have been instrumental in gaining support from independent foundations that will help us to begin the process of developing worthwhile projects. Obtaining research grants can be a difficult process and the National Institute of Dental and Craniofacial Research (NIDCR) likes to see some type of track record before allocating funds.

Its well-known that most patients seek care in a medical or dental setting due to pain. One thing I want to emphasize to our students is that connecting with patients is very different in a pain/sleep clinic than in a typical dental office. I spend a lot of time getting the patient’s story, history, and making sure they felt cared-for. This came from my training with Dr. Gremillion – in many situations, I still find myself thinking “What would Henry do?” This is missing from most dental training these days. As dentists we are mostly taught to be therapists as opposed to good diagnosticians. We often get frustrated if we cannot “see” a problem to fix. Learning to connect with our patients is a powerful way to improve encounters between medical professionals and the people they serve. The better we can do with this, the happier patients we have. I think dentists trying to become well-regarded by the medical doctors in their communities should emphasize this in their practices. Focus on your patient’s story, create an exceptional experience for them, and they will tell the sleep docs about you. Here at the Center, we will always emphasize the person attached to these often-complicated pain and sleep problems.

DSP: I would think at a major institution that you also have access to the latest equipment, too.

SB: Sure, it’s nice to have a radiology department right across the hall, but dentists

CLINICIANspotlight don’t need a lot of fancy equipment to treat pain and sleep patients well. As the new guy, I’m not asking for much yet, but I really don’t think that it’s about the gadget – it’s about what you know, what you can learn from the patient, and how you put those together to create the right treatment plan.

DSP: What else would you like the readers to know about your Center or treating patients in general? Do all dentists treating sleep need to study at a place like yours?

SB: Well, like I said, being successful at helping patients in pain or with sleep problems, or both, requires a thorough diagnosis.

Involving the patient’s medical doctor is a must. We should also develop working relationships with other physicians and allied health care providers to ensure the best care for our patients. Currently, physicians are

better trained in taking a proper history and performing a physical examination. We need to work with them to ensure that the patient is properly diagnosed and receives the most appropriate care.

Do dentists need to come to the Texas A&M Center for Facial Pain and Sleep Medicine? Well, certainly I hope that what we will offer will be a great place to learn. There are other programs of excellence around the country, but we do hope to add something unique. What dentists need to do above all is to see treating sleep disorders is not just about making an appliance and getting paid for it. It’s about creating a patient-doctor partnership. I’ve found that once the patient embraces this partnership, they can gain control of their conditions and that speeds the healing process. We need to develop a team approach to ensure our patients are well cared for for their lifetime.

Photos courtesy of Steven Doll, Texas A&M University College of Dentistry

Physiological Monitoring for Dentistry and Medicine The future of dentistry lies in recognizing the dentist’s role in understanding and improving patient physiology.

Visit us and find out more at the AAPMD Airway Summit “Building A Collaborative Community for Optimal Health” September 15-17, 2016 at the Hilton El Conquistador Resort in Tucson, Arizona.

physiologicaldentistry.com

DentalSleepPractice.com

21

MANUFACTURER’Scomments

Jaw Positioning More than

by Dr. Mark E. Abramson

I

n the recent review of oral appliances in Dental Sleep Practice I was very happy to see such a positive review of the unique features in the OASYS Oral/Nasal Airway System. It remains the only appliance that treats the entire upper airway and is FDA cleared to function both as a mandibular repositioner and a nasal dilator. Its ease in using with patients with upper dentures makes it easy to categorize as a specialty appliance.

Every new patient should be tested for nasal resistance with the Cottle Maneuver

The greatest body for swimming and a perfect example of using the mentalis to close the lips together.

22 DSP | Fall 2016

Nasal resistance is second only to obesity as a cause of OA treatment failure.1 The top doctors who use the OASYS use the additional features of the device for more clinical effect. Pads that dilate the external nasal valve and positioning pads that lift the back of the tongue and improve the swallow pattern are value-added features that improve their treatment outcomes.

OASYS features a movable shield that extends from the mandibular base under the upper lip. The shield rests against the maxilla and is used to reposition the mandible. One of the comments in the review was that it might be too thick and make it difficult for the upper lip to seal against the lower lip, achieve lip competency and guard against mouthbreathing.

As I was looking at the positives and negatives of my appliance compared to others, I looked closely at this detail with my patients and got feedback from other doctors who routinely use the OASYS for their patients. I began to see the upper shield as having a great advantages and so I’d like to take this opportunity to talk about it.

Let’s start off looking at cases with nasal resistance. John Remmers, M.D. states that 30% of your patients will need treatment of the nose, 80% would benefit from it and 20% doesn’t really matter that much. So you can see that the majority of your pa-

tients will receive benefit from having their nasal obstruction or resistance addressed.

If we look at patients with nasal issues we see that we might have on one end of the spectrum a patient who’s facial development looks relatively normal but they have nasal resistance. They have lip seal during the day but find the easy path for breathing during sleep and start to breathe through their mouth. At the other end of the spectrum are the true mouth breathers who are going to present with a short upper lip and a dry, enlarged lower lip. They likely have a narrow high arched palate. The dry enlarged lower lip comes from air flow through the mouth. In order to close their lips they have to use the mentalis muscle to push the lower lip up to meet the shorter upper lip.

For anyone on the nasal-resistance spectrum, when they go into REM sleep the lining of nasal passage swells up to increase flow resistance. They are going to find the easiest route to breathe, which would be through their mouth. If you make them a general mandibular repositioner such as a dorsal fin, Herbst, or any other unattached appliance, as soon as the mouth is opens and mouth breathing begins, the tongue has to drop down to the floor of the mouth. As the mandible is swung open in a hinge-like movement,

MANUFACTURER’Scomments

Even with lips parting the anterior oral seal is maintained

O2 OASYS

the tongue and other soft tissues can move toward the back of throat and all stable support of the airway is lost.

The OASYS shield allows the lips to part without losing airway seal. The nasal dilators provide the patient the ability to continue to breathe through their nose and support nasal breathing throughout the night. With nasal breathing the tongue can go into its proper position in the palate and complete the oral seal by allowing the soft palate to seal behind the tongue at the posterior of the oral cavity. This important tongue function is like the third leg of a stool, giving the mandible stability as well as stabilizing the structure of the throat and airway.

For patients that we cannot convert to nasal breathing, the OASYS can be made with a space to allow mouth breathing but I prefer to have it made with minimum space between the stable lower base and the movable shield. This space can be sealed with orthodontic wax for people who complain

that their mouth is dry, indicating ongoing mouthbreathing. I also make sure the nasal dilators are properly adjusted.

Even with patients who have been chronic mouth breathers and have a short upper lip, we can use the OASYS as a therapeutic appliance for them with two goals: converting them to nasal breathers while maintaining an open airway. Over time, the shield will actually help them to stretch out their upper lip so that they don’t have to use the mentalis muscle to push their lower up to the short upper lip in order to close lips together. Initially I might have patients use some very light paper tape to tape their lips closed. I do not meet with much resistance, especially after I explain to them the benefit and give them assurances that most patients do not find it a problem.

The original idea for making an appliance with the repositioning element in front of the upper arch was to maximize tongue space so that the only material on the lingual of the anterior teeth is the thin upper cushion. The tongue has the soft comfortable feel of the natural dental surface. For maximum comfort, the shield also acts like a slip joint allowing mandibular movement in all directions without binding and translating forces onto the dental arch.

I hope this helps the reader understand why I designed the OASYS with its unique features.

1.

Zeng B; Ng AT; Qian J; Petocz P; Darendeliler MA; Cistulli PA. Influence of nasal resistance on oral appliance treatment outcome in obstructive sleep apnea. SLEEP 2008;31(4):543547.

Dr. Mark Abramson is a TMJ and Sleep Apnea dentist, serving patients in Redwood City, in the San Francisco Bay Area. He attended the University of Maryland School of Dentistry where he graduated in 1975. Upon graduation he came to California to do a general practice residence at the Palo Alto Veterans Hospital. After his residency, he limited his dental practice to treating the special needs of those suffering with TMJ and headache and facial pain.

Dr. Abramson is a Diplomat, American Academy of Orofacial Pain; Diplomat, Academy of Pain Management; Diplomat, American Academy of Dental Sleep Medicine; and a Fellow, American Academy of Craniofacial Pain Management. He is a member of the American Dental Association, California Dental Association, American Academy of Dental Sleep Medicine where he is on the program committee, American Academy of Craiofacial Pain Management, Cranial Academy and his dental license is extended to include acupuncture treatment.

Dr. Abramson developed the O2 OASYS Oral/Nasal Airway System™ and in 2004 received FDA approval for this device.

Dr. Abramson directs Stanford University’s Mindfulness Based Stress Reduction Clinic and teaches ongoing classes on this program through Stanford University School of Medicine. Dr. Abramson is a staff physician at Stanford University Hospital.

24 DSP | Fall 2016

Supporting Dentists Through Practical Sleep Apnea Education

3 Ways

to Subscribe Visit: www.DentalSleepPractice.com E-mail: subscriptions@medmarkaz.com

4 issues per year

Call: 1-866-579-9496

99 $ 219 Best Value!

1 year: $

3 years:

PRACTICEdevelopment

Is your website really working?

Ian McNickle, MBA, discusses how to convert website visitors into new patients

T

he world of websites and online marketing can be confusing. Dentists and their staff often feel as though their website could be doing more for them, but aren’t quite sure how to determine this or what to do about it. The goal of this article is to help you understand how to get more value and new patients from your website.

The goal of online marketing

Online marketing is primarily concerned with the following two objectives: 1. Driving traffic to the website 2. Converting that traffic to take the actions you want them to take Driving traffic to your website is achieved by the use of search engine optimization (SEO), pay-per-click (PPC) paid ads, social media, review sites (Google+, Yelp, Facebook, Healthgrades®, etc.), and other methods. Once people arrive at your website, you’ll want them to take action to contact your office via phone call, email, or filling out an appointment request form. These actions are called “website conversion.”

The ultimate marketing goal of the website is to drive new patients to the practice.

This is achieved by maximizing both traffic and website conversion.

The focus of this article will be on website conversion, and our next article will focus on driving traffic.

Improve your website conversion rate

Far too many dental practices use common, templated websites with stock photos and stock content. This does not differentiate you from other practices and does not reflect the unique personality of your practice. In addition, the calls to action are often poorly implemented.

Instead, consider implementing the following items to improve your website conversion: • A custom website design should properly reflect your practice.

• Phone number should be easy to find at the top of every page in large font.

• Appointment request button (or form) should be easy to find on every page and be located further up the page (not at the bottom).

• Use actual photos of the practice, staff, and equipment with minimal use of stock photos.

Receive your free marketing consultation today: 888-246-6906 or info@weomedia.com

26 DSP | Fall 2016

PRACTICEdevelopment • Write unique content that is specific to your treatment philosophy and approach. • Embed an overview video of the practice on the home page to help communicate who you are/your personality, what is unique about your practice, highlight technology and training, etc.

Track and optimize results over time

In order to properly track conversion, we always recommend using a phone call tracking number that routes to your actual office phone. Using a tracking number will allow you to more accurately understand how many calls are coming from your website.

We also recommend recording the phone calls for training purposes.

Dental practices that want to get the most from their online marketing efforts should make it a regular monthly activity to review website traffic and conversion. Plotting these trends over time will allow practices to understand if their activities to increase traffic

are working, if their conversion rate is getting better, and to determine the return on investment (ROI) for this portion of their marketing.

Marketing consultation

If you have questions about your website, social media, or online marketing, you may contact WEO Media for a consultation to learn more about the latest industry trends and strategies. The consultation is FREE if you identify yourself as a reader of this publication.

Ian McNickle, MBA, is a national speaker, writer, and marketer. He is a co-founder and partner at WEO Media, winner of the 2016 Cellerant Best of Class Award for Dental Marketing and Dental Websites. If you have questions about any marketing-related topic, please contact Ian McNickle directly at ian@weomedia.com, or by calling 888-246-6906. For more information, you can visit www.weodental.com.

DentalSleepPractice.com

27

MEANINGFULconversations

Post Graduate Education is the Key to Sleep Apnea and Craniofacial Pain Treatment Success

by Mayoor Patel, DDS, MS

D

ental Students typically spend eight years total in college preparing for clinical practice. It’s in the last years where they learn about sleep apnea and craniofacial pain treatment. Or do they? With few to no hours dedicated to these services, postgraduate education remains vital in procuring a successful sleep apnea and craniofacial pain practice.

Inadequate Education

Students are missing out on the education necessary for advanced services in sleep apnea and craniofacial pain. A national survey conducted by Rutgers medical schools, indicated on average, less than two hours of total teaching time is allocated to sleep and sleep disorders while 37 schools reported no structured teaching time in this area. In fact, only 8% of medical students trained in the use of sleep laboratory procedures and 11% have participated in the clinical evaluation of sleepdisordered patients.1

28 DSP | Fall 2016

Dentists are receiving even less education in school in these areas. Dental students, on average, are only spending 2.65 hours on sleep apnea. In fact, a survey sent to general dentists reported 58% could not identify common signs and symptoms of obstructive sleep apnea while 55% did not know the mechanism for mandibular advance devices.

Additionally, only 16% said they were taught about this issue in dental school and 40% knew little or nothing about sleep apnea treatment for patients. However, 30% did indicate they learned from postgraduate training.2 This data shows schools are missing the necessary resources to support sleep apnea and craniofacial pain courses, but the availability of postgraduate education can solve the lack of information for providing proper treatment.

Postgraduate Education

Unqualified faculty, a lack of curriculum and the need for additional clinical

MEANINGFULconversations educational resources creates a need for postgraduate education for dentists. In a position paper published in SLEEP it is mentioned that oral appliances should be fitted by qualified dental personnel who are trained and experienced in the overall care of oral health, the temporomandibular joint, dental occlusion and associated oral structures.3 Meaning, postgraduate education is key for treatment success.

From introduction courses in the field of dental sleep medicine and craniofacial pain to advanced courses and mini-residencies for those who have completed several seminars and are ready for in-depth programs, there are many options available for continuing education. See Table 1.

If you want to become proficient in dental sleep medicine and/or craniofacial pain it is vital that you take quality educational courses. While some courses might claim to provide all of the education necessary to provide services in the intended fields within a day or even only a couple of hours, these courses

might simply be out there to make money – it is imperative to do some research first.

In order to become accomplished in dental sleep medicine and craniofacial pain, it is important to take the necessary post educational courses for the allotted number of credits before being able to provide the appropriate services for patients. Any patient has the potential to become complex, training will help you provide this critical service with confidence.

Using the summary list in Table 1 and others, you can find the right educational path for you. Ask questions and be sure you are investing your time and money wisely. Treating sleep patients is challenging – but fun and rewarding! Confident, successful therapy begins with excellent preparation.

1.

2.

3.

Rosen, RC, M. Rosekind, C. Rosevear, WE Cole, and WC Dement. “Physician Education in Sleep and Sleep Disorders: A National Survey of U.S. Medical Schools.”

Bian, Hui. “Knowledge, Opinions, and Clinical Experience of General Practice Dentists toward Obstructive Sleep Apnea and Oral Appliance.”

“Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: An Update for 2005”

Table 1: Continuing Education Courses in Dental Sleep Medicine Organization

Introduction

Advanced

Mini-Residency

Nierman Practice Management (SCOPE INSTITUTE)

3

3

3

AADSM

3

3

American Academy of Craniofacial Pain

3

Dr. Jonathan Parker

3

Rondeau Seminars

3

Sleep Group Solutions

3

Dr. Kent Smith

3

Most Dental Conventions

3

Dental Institutes (Dawson, Pankey, LVI, Spear, etc.)

3

3

3 varies

Tufts University

3

UCLA

3

University of the Pacific

3

University of San Francisco

3

List does not include every course available.

Having a limited practice to Craniofacial Pain and Dental Sleep Medicine, Dr. Mayoor Patel, DDS, MS, D.ABDSM, D.ABCP, D.ABCDSM, D.ABOP, utilizes his experience and expertise to help dentists across the country excel in these areas within their dental practices. As Clinical Education Director with Nierman Practice Management, Dr. Patel develops up-to-date curriculum for their sleep apnea and craniofacial pain programs. Dr. Patel serves as a board member with the Georgia Association of Sleep Professionals, the American Board of Craniofacial Dental Sleep Medicine, American Board of Craniofacial Pain and American Academy of Craniofacial Pain. He also has taken the role as examination chair for the American Board of Craniofacial Dental Sleep Medicine and American Board of Craniofacial Pain.

30 DSP | Fall 2016

PRACTICEmanagement

Knowledge is

POWER Hold on to those Reimbursements

by Rose Nierman, RDH, Founder and CEO Nierman Practice Management

I

t’s wonderful that so many dentists are successfully billing medical insurance to help their patients with access to care for oral appliances. When billing in this arena, it’s important to possess knowledge of medical policies which provide your practice with the “power tools” to more easily receive reimbursements and also to retain those reimbursements. Since misinformation about medical billing and coding that can be detrimental to a dental practice is commonly presented, knowledge of current medical policies for Dental Sleep Medicine and TMD appliances is essential. Misunderstood terms can also come into play. As an example; during our recent Medical-Billing-for-Dentists seminar in Atlanta, a participant stated, “we don’t have to worry about following documentation guidelines or requests for refunds because we bill out-of-network.” This statement is far from the truth. The act of billing or providing a patient with codes opens the door for insurers to verify that the billing is correct. Even when using a third party biller, it’s essential to have knowledge of the correct codes, ethical billing protocols, necessary documentation and what’s being billed. The dental practice is, ultimately, responsible for the codes billed and for generating the necessary narrative reports and documentation.

Thus, training and education in medical billing for dentists is as important as clinical training for oral appliance therapy. We have seen a few audits in Dental Sleep Medicine (DSM) and Temporomandibular Dysfunction (TMD) and expect reviews to increase as progressively more patients are undergoing these life-changing treatments.

A Few Questions to Consider Are you up-to-date on documentation requirements that support evaluation and management codes that you bill? Did you know that the American Medical Association, in conjunction with The Center for Medicare and Medicaid Services (CMS) created Guidelines for Billing Evaluation and Management Codes? This guide shows how to document the extent of your verbal “Review of Sys-

32 DSP | Fall 2016

PRACTICEmanagement tems,” specific “Examination Elements” and the level of medical decision-making.

Are you aware of recent changes in some commercial insurance policies specifying that using a “Medicare-cleared” (PDAC approved) OSA appliance is now a requisite for reimbursement? Do you question whether you can bill on the date of the impression or upon delivery?

Are you up-to-date with insurance carrier policies, regarding the need of an MD prescription, Proof of Delivery form and other documentation for an OSA appliance?

Can you bill for a morning re-positioner as an accessory to the sleep appliance or is this “nickel and diming” commonly referred to as “unbundling”?

Are you sending narrative reports to the patient’s other physicians – and how important is this to communications when treating a medical condition such as OSA? These are important questions to be answered and underscores the importance of education in medical billing for dentists and

risk management when providing DSM and TMD services.

Pursue the knowledge and “power tools” to stay current with documentation requirements for TMD and OSA. To ensure the maximum reimbursement and compliance, consult an expert or attend an educational program designed to provide the answers to these burning questions. Empower your practice with the knowledge to be successful!

Rose Nierman, RDH, is the Founder and CEO of Nierman Practice Management, an educational and software company (DentalWriter™ and CrossCode™ Software) for Medical Billing for Dentists, TMD and Dental Sleep Medicine advanced treatment, and co-founder of the SCOPE Institute, a non-profit educational organization dedicated to the advancement of sleep apnea, craniofacial pain treatment, and medical billing within dentistry.

Rose and her team of clinical and medical billing experts can be reached at Rose@Dentalwriter.com or at 1-800-879-6468.

AAPMD Airway Summit Building a Collaborative Community for Optimal Health

30+ Speakers Focused Workshops Networking Events

September 15-17, 2016 Hilton El Conquistador Resort | Tucson, Arizona

www.aapmd.org DentalSleepPractice.com

33

TECHNOLOGYupdate

DIGITIZATION of Dental Sleep Medicine by Tarun Agarwal, DDS, PA

E

verywhere you turn dentistry is going digital. Now even dental sleep medicine is going digital! This is just the beginning, but the fact that digital dentistry is placing its mark on OSA therapy gives me great confidence in the growth potential of dental sleep medicine.

Let’s take a look at a few areas where digital dentistry makes OSA therapy more efficient, predictable, and profitable. The beauty of this digitization is that it is not exclusive to just sleep therapy.

This is technology that you are or could already be using for many different areas within your practice – diagnostics, implant planning, orthodontic planning, and restorative dentistry. Now it has the ability to add dental sleep medicine to the mix.

Creating Patient Awareness

It’s great to work with the low hanging fruit of CPAP failures, but the real growth in your OSA practice comes when you can help get the roughly 80% of undiagnosed sufferers on their way to healthier sleep breathing. To do this you must find a way to create awareness and urgency in those unaware. For me

Figure 1: Airway segmentation from 3D CBCT used to create awareness of undiagnosed patient.

34 DSP | Fall 2016

this is best done by utilizing 3D CBCT imaging (Figure 1).

While NOT diagnostic for OSA, it certainly creates an avenue to having a conversation and encouraging your patient to have either an HST (Home Sleep Test) or in lab PSG. Since implementing airway segmentation into regular hygiene recare visits and new patient visits we have seen an increase of unaware patients entering into our OSA therapy workflow.

Reducing Chairtime

Digitization also helps increase your profitability by reducing chair time. Nothing is more expensive in your practice than your chair time. Adjustments and remakes can wreak havoc on your profitability and not to mention patient confidence.

The fit of your OSA appliance is an important part of patient comfort, compliance, and effectiveness. Too often we spend time adjusting appliances due to poor quality impressions and general inaccuracies of analog fabrication methods. We can now leverage digital impressions to produce appliances that are more accurate and minimize adjustments (Figure 2).

Figure 2: CEREC used to create ‘distortion free’ impression to minimize adjustments and provide a better fit.

TECHNOLOGYupdate Another unrealized benefit of digital impressions is faster turnaround time. It is often hypocritical of me to tell the patient the importance and urgency of getting into an appliance and in the same breath tell them it will take several weeks for the lab to make the appliance. Digitization has allowed us to get appliances back in about a week (Figure 3).

Figure 3: Combination of 3D CBCT along with airway segmentation to provide a direct digital appliance fabrication – resulting in quicker turnaround times.

The Bigger and Complete Picture

Dental sleep medicine is truly an area where we can begin to help patients with overall health improvement. As with any health therapy there are potential complications and/or side effects. 3D imaging gives us an opportunity to evaluate many of these areas prior to commencing therapy.

One area that has long been a concern for OAT has been its potential affect on the joint. While there are many reasons for this, most commonly it’s due to undiagnosed joint issues prior to treatment or an inappropriate bite putting the joints in an uncomfortable position. 3D imaging allows you to visualize the joint pre-treatment and avoid potential issues (Figure 4).

Being able to evaluate the joint is a worthwhile benefit of 3D imaging. At the same time we can also measure potential airway change. Using the same 3D image we can also measure the airway with the bite and/or appliance in place. Personally, I prefer to take it with the bite in place. This allows me to compare the potential airway changes prior to having the appliance fabricated (Figure 5).

Figure 5: Here we can see our pre-appliance treatment position creates an increase in the minimal cross section of 16mm2 to 40mm2 – nearly a 3x increase in airway opening.

Please don’t misunderstand me. A post treatment HST or PSG is the ideal and standard measure of treatment effectiveness.

Having the ability to measure airway, evaluate joint position, and see anatomical deviations gives me a more complete picture of airway therapy. This leads to more predictable results and better communication between dentist, physician, and patient.

Digital dentistry has made restorative and implant dentistry more predictable, efficient, and improved clinical outcomes. It is poised to do the same for oral appliance therapy.

This is just the beginning and it’s exciting to see what is in store for the future.

Dr. Tarun Agarwal is a nationally recognized lecturer in the field of aesthetic and restorative dentistry. He practices in Raleigh, NC. In July 2002, he co-founded the Dentaltown “Townie Meeting” an annual event considered one of the most progressive educational opportunities in dental education. Dr. Agarwal has assisted numerous dental manufacturers in new product development and review.

He has been featured on ABC, NBC and CBS news and several consumer magazines for his pioneering use of technology, philanthropic events, and aesthetic dentistry. In 2003, Dr. Agarwal was voted the “Townie of the Year” for his contributions to the growth and dynamics of the dental community.

Figure 4: A view of the joint in treatment position.

DentalSleepPractice.com

35

TEAMfocus

Patient Education!

The single most important topic.

by Glennine Varga, AAS, RDA, CTA

D

ental Sleep Medicine is an industry that is taking off in leaps and bounds. Many dentists in the US and abroad are becoming educated on sleep airway and the importance of a good night’s sleep. Some of these dentists are offering oral appliance therapy to their patients and very few are solely focusing on dental sleep medicine with their patients. Regardless, if an office is occasionally offering oral appliances or is exclusively dental sleep medicine, patient education is the key to long term success.

In 1960, dental insurance companies offered benefits to enrolled subscribers which was equivalent to approximately $1,000.

Today, most dental insurance companies offer the exact same benefits as in 1960. In 56 years most dental insurance companies have not increased benefits to keep up with inflation and the cost of living. How has the dental field survived? How have dental of-

36 DSP | Fall 2016

fices become successful? Only doing simple cleanings and yearly exams? NO. For decades dental educational entities have focused on one important factor‌patient education! The dental profession learned early on it is imperative to educate patients regarding needed treatment especially when needed treatment costs extend past insurance benefits.

Patients that are in need of oral appliance therapy need it whether insurance is involved or not and an educated patient will make educated decisions. When patients understand they may have benefits with their medical insurance for oral appliance therapy, the focus tends to shift toward benefits instead of the need for therapy. You can reinforce the good news that your solution for their problem has benefit with most insurance policies, but the real message needs to be that treating their airway is more important than whether the oral appliance is part of their insurance contract.

TEAMfocus Here are 3 ways to focus on educating your patients and empowering them to make educated decisions toward therapy.

1. Communicate and educate keeping your patient as the main focus. As dental team members we are given many tasks and responsibilities which can bog down our daily thoughts and actions. It is important to keep your patient’s perception in mind and focus on what he or she may feel is important. For example, if a patient asks why sleep is a topic of conversation in the dental practice, a typical response may be “because we make oral appliances for patients with sleep apnea”.

This could be perceived by the patient that sleep is a conversation topic because it’s a sales tactic instead of a genuine concern. So if the question of why sleep is a topic comes up, a great response would be “because our office is concerned with your overall health and wellness.”

2. Educate patients before referring them for a primary diagnosis. It is appropriate for a sleep physician to diagnose patients with sleep breathing disorders as a result of a sleep test.

Therefore, referring patients to obtain a diagnosis is common for most dental sleep medicine dentists. It is important that the patients understand the process and, depending on what is diagnosed, oral appliances may be a great therapy option. Dentists complain that after referring patients out most don’t come back and most are only given Positive Airway Pressure (PAP) therapy as a treatment option. So educate your patients before referring them out. Hand them an oral appliance brochure. The focus of a high risk non-diagnosed patient is to obtain a diagnosis with mention of oral appliances as a possible option.

3. Educate normal sleep study results versus patient results. In dentistry, patients respond better when they understand what is wrong and why it needs to be fixed. The same should be said for sleep. Most obstructive sleep apnea (OSA) diagnosed patients cannot explain AHI, SPO2 levels or percentage of N3 sleep. Most of these patients

WE can educate patients to make educated decisions toward therapy! are only told if they have apnea or not and what level of severity was diagnosed. If we give patients the opportunity to learn what normal sleep looks like and compare their sleep measures to that standard, we will help patients lean toward therapy.

Educating patients is the single most important topic. Four out of four of my immediate family members have been diagnosed with a sleep breathing disorder. Only one originated from a medical entity, was diagnosed with mild OSA and was told no treatment was needed. As a family member and dental professional, I couldn’t let that go and talked with them until all four were diagnosed; now they are all in OSA therapy.

My point is medical offices do not have time to evaluate every patient for sleep breathing disorders and unless a patient’s chief concern is sleep breathing, most times sleep will never be discussed. WE dental team have time!

WE can have conversations with patients and screen for this! WE can educate the importance of obtaining a diagnosis! WE can educate patients to make educated decisions toward therapy!

Editor’s Note: This Sleep Team Column will be dedicated to the team and provide practical tips and resourceful information. Let us know your specific issues by email to: SteveC@MedMarkAZ.com, while we can’t respond to every individual. Your feedback will help us create the most useful Sleep Team Column we can!

Glennine Varga is a certified TMD assistant and educator with an AA of sciences. She is a certified TMD assistant with the American Academy of Craniofacial Pain. She has been employed in dental education for over 19 years. Glennine has been a TMD/Sleep Apnea trainer and speaker with emphasis on medical billing and documentation for over ten years and a trainer of electrodiagnostic equipment for five years. Glennine is CEO of Dental Sleep Medicine Boot Camp and a Total Team Training instructor for Arrowhead Dental Lab. For more information, visit www. dsmbootcamp.com or email g@dsmbootcamp.com.

DentalSleepPractice.com

37

ORGANIZATIONspotlight

Learning Sleep from AADSM

An interview with Harold A. Smith, DDS, president of the AADSM

A

s more dentists are choosing dental sleep medicine as a way to expand their practices and help patients, there is an increasing number of education and training opportunities in oral appliance therapy provided by dental schools and professional associations.

A commitment to ongoing education benefits dental sleep medicine professionals and enables them to provide quality care.

38 DSP | Fall 2016

The American Academy of Dental Sleep Medicine (AADSM) offers several educational courses for both novice and seasoned dentists, ranging from literature reviews to practical clinical applications. In an interview with AADSM President Harold A. Smith, DDS, he discusses the AADSM educational courses and how they can help dentists excel in dental sleep medicine.

There is a lot of education available in sleep today – probably once a month in major cities across the country a dentist can find a sleep course.

What makes AADSM courses different, something to seek out? Why is AADSM involved?

The American Academy of Dental Sleep Medicine is the only non-profit national professional society dedicated exclusively to the practice of dental sleep medicine. We offer continuing education because we know it’s extremely important for our members to stay up-to-date on advances in oral appliance therapy and provide quality treatment for snoring and sleep apnea.

All AADSM courses are recognized by the ADA Continuing Education Recognition Program (CERP), acknowledging them as quality continuing dental education. AADSM courses offer introductory and advanced-

level education in dental sleep medicine, providing a comprehensive approach to oral appliance therapy. Courses cover the knowledge needed to treat a medical disease, the clinical skill required to fabricate and adjust oral appliances, and the fundamentals of dental sleep medicine practice management.

Dentists must continuously identify ways to demonstrate their proficiency in the fast-growing field of dental sleep medicine to be successful in networking and generating patient referrals. A commitment to ongoing education benefits dental sleep medicine professionals and enables them to provide quality care – and the AADSM is proud to play a role in helping dentists optimally treat their snoring and sleep apnea patients.

Please tell us about your faculty – how were they chosen? What type of practice do they come from? What’s special about them? Do dentists hear from just other dentists? Is there an MD perspective? What do they teach?

AADSM faculty are chosen due to their outstanding credentials in the fields of dental sleep medicine and/or sleep medicine. Lecturers speaking as dental experts are licensed dentists (DDS or DMD) with significant experience treating sleep-disordered breathing patients with oral appliance therapy, and they are either a board-certified Diplomate of the ABDSM, director of an AADSM-accredited facility or an educator in dental sleep medicine. In addition to dental sleep medicine, some faculty members have a background in other related fields such as oral surgery, pulmonology and respiratory care.

ORGANIZATIONspotlight Many AADSM courses also feature an MD lecturer who discusses sleep-disordered breathing from a medical perspective, including an overview of sleep-related breathing disorders, polysomnogram reports, medical terminology, the comorbidities of untreated sleep apnea, and the development of a team approach to patient management. All of the medical lecturers are passionate about the role of dentists in the management of sleep-disordered breathing patients and represent a diverse mix of backgrounds in sleep medicine.

Faculty members represent a variety of practice settings, such as dental sleep medicine private practices, combined dental sleep medicine/general dentistry practices, sleep medicine clinics, hospitals and universities.

Both dental and medical faculty members often have demonstrated leadership in the field as board members of relevant professional associations, editors or contributors to peer-reviewed journals, awarded researchers, and clinic and department directors.

I see you have not only intro courses but advanced, team, and practical courses. Is this designed as a group – do dentists take all the courses before they are ready to treat patients?

Dentists are not required to take AADSM courses in order to administer oral appliance therapy, nor are they required to take the courses in a particular order. For those who are seeking a holistic approach to dental sleep medicine, we recommend that they start with our Essentials of Dental Sleep Medicine Course, followed by the Practice Demonstration Course. Dentists of all experience levels also are encouraged to attend the AADSM annual meeting, which is the premier educational event in dental sleep medicine. The AADSM 26th Annual Meeting will be held in Boston from Friday, June 2, through Sunday, June 4, 2017.

In addition to in-person courses, the AADSM offers Q&A webinars, online modules, practice management support and online study clubs to provide a simple, convenient way to earn CE credits and become more knowledgeable in the field.

What about sleep tests – do dentists get hands-on learning with how to use home sleep monitors?

AADSM courses may provide information about how home sleep apnea testing (HSAT) is used by physicians to diagnose sleep apnea. However, the AADSM does not promote the use of HSAT by dentists as a screening or diagnostic tool.

Many dentists are interested in becoming Diplomats of ABDSM. Do the AADSM courses count toward the required CE and prepare the attendee to take the examination?

Yes, AADSM courses count toward the continuing education prerequisite for ABDSM board certification applicants. Additionally, the AADSM hosts an annual Board Review Course to help applicants prepare for the ABDSM certification exam. The one-and-ahalf-day course helps participants understand the scope of the exam based on the weight given to each topic, review journal articles on the ABDSM reading list, discuss mock questions, determine appropriate investigative strategies and develop a comprehensive patient treatment plan.

Through continuing education and earning dental sleep medicine designations, such as ABDSM Diplomate certification, dentists can demonstrate to physicians, patients and payers that they are dedicated to providing optimal patient care with oral appliance therapy to treat obstructive sleep apnea.

All of the medical lecturers are passionate about the role of dentists in the management of sleep-disordered breathing patients.

Harold A. Smith, DDS, is the president of the American Academy of Dental Sleep Medicine (AADSM). He has provided oral appliance therapy since 1993 and is currently the clinical director of Dental Sleep Medicine of Indiana. He also serves as the dental consultant to the major Indianapolis hospital sleep disorder centers and is on faculty at Indiana University School of Medicine’s Fellowship program in sleep medicine.

As a distinguished speaker and ABDSM Diplomate, Dr. Smith has lectured nationally on the dentist’s role as part of a medical team in sleep medicine. He also has served on many levels of organized dentistry throughout the years.

Dr. Smith is a Fellow of the American College of Dentists and is an active member of the AASM, ADA, IDA, IDDS and AGD. He is a graduate of the Indiana University School of Dentistry.

An active and passionate dental sleep medicine professional, Dr. Smith served as president of the AADSM from 2002 to 2004, received the AADSM Distinguished Service Award in 2006 and was president of the ABDSM from 2008-2010.

DentalSleepPractice.com

39

NUTRITION

Helping Sleep Patients Understand

How to

Lose Weight

by Dr. Warren Schlott

O

ne of the most effective treatments for obstructive sleep apnea is weight loss. However, as the medical community struggles with dynamic changes and as physicians become busier and busier, less time is spent counseling sleep patients about weight loss. If the sleep dentist truly wishes to help his sleep patients improve, the sleep dentist should know the basics of weight loss and be able to counsel patients when appropriate. Staying with the science can help with what can be an uncomfortable subject.

40 DSP | Fall 2016

Understanding weight loss requires knowledge of the physiology of weight gain and weight loss, and subsequent behaviors that can lead to physiological change in the body. People eat foods that consist of carbohydrates, protein, fats, and/or fiber. Each of these has a different effect on the body.

Carbohydrates Not so long ago, excess fat consumption was thought to be the leading cause of weight

NUTRITION gain. Today, we know that carbohydrates are the culprit.1 Even though carbohydrates are the main source of energy for the body, it is known that not all carbohydrates are created equal. Simple carbohydrates, also known as refined carbohydrates, found in such foods as table sugar, white flour bread, cakes, fruit, candy, potato chips, breakfast cereals, and the like, are made up of only one or two glucose molecules. These simple molecules are rapidly absorbed by the digestive tract and cause a spike in blood sugars. These foods have little nutritional value, and if eaten in excess the body sends these carbs to the liver to be stored as fat throughout the body.2 On the other hand, complex carbohydrates, made up of three or more glucose molecules linked as a chain, and found in such foods as vegetables, legumes, and whole grains, take longer to digest. Usually, these foods contain vitamins and nutrients that are beneficial to the body.

For every 10 calories of carbohydrates eaten, the body burns 1 calorie to convert the carbohydrate to sugar.3 Typically, about 70% of the sugars are rapidly absorbed into the bloodstream and burned off as energy in about 6 hours. The remaining 30% is converted to triglycerides and stored in fat cells.

Carbohydrates raise the blood sugar which triggers insulin release from the pancreas.

Insulin clears the glucose (sugar) from your bloodstream. As the blood sugar drops, craving for more carbohydrates increases. If more carbs are eaten, insulin production spikes and then falls and these cycles can become persistent. In many cases, over time, excess production of insulin leads to the body becoming immune to the effects of insulin and type 2 diabetes occurs. Fortunately, not all carbohydrates digest at the same rate. Some raise blood sugar levels faster than others.

The ability to raise blood sugar is defined by the glycemic index.4 The higher the index number, the more elevated the blood sugar level becomes when eaten. Generally, carbohydrates with a number higher than 70, cause an extremely fast rise in blood sugar resulting in spikes of insulin that encourages fat storing. Carbohydrates with a glycemic index below 55 cause a lower rise in blood sugar and insulin, and hence, make you feel not hungry longer. Carbohydrates between

55 and 69 cause a moderate rise in blood sugars and insulin. There are reference books that list the glycemic index for most foods.

Obviously, it is beneficial to eat carbohydrates that have a lower glycemic index.

Fats Fat, once thought to be the bane of diets, are now understood to have beneficial and needed requirements for a healthy diet.5 Of course some fats are better than others.

Monounsaturated and polyunsaturated fats are considered healthy. Monounsaturated fats improve cholesterol levels, enhance insulin sensitivity, and help stabilize blood sugar levels. Foods such as olive oil avocados, almonds, and other nuts contain monosaturated fats. PolyunsatStaying with the science urated fats contain omega-3 and omega-6 fatty acids and can help with what can be help reduce inflammation. Soyan uncomfortable subject. bean oil and fatty fish such as salmon contain polyunsaturated fats. Saturated fats are found in meats, cheese and butter, and in some plant oils such as coconut and palm oil.

These fats are beneficial in small amounts.

Trans fat, on the other hand, is the worst fat for you. These fats are man made by hydrogenation of unsaturated fats. These fats are made to increase shelf life of certain foods such as baked goods. Trans fat has been implicated in rising LDL (bad cholesterol) levels and decreasing HDL (good cholesterol).

All fats are high in calories. Whereas, carbohydrates contain 4 calories per gram, fat has 9 calories per gram; and it only takes 1 calorie to digest 100 calories of fat. Fats are energy storehouses.

Warren J. Schlott has been a practicing dentist in Brea, California since 1978. Dr. Schlott developed a thriving restorative dental practice and then in the early 2000’s developed a busy full time sleep practice. He has published numerous articles, and has helped other dentists establish sleep practices. Dr. Schlott is a member of the American Academy of Sleep medicine and is a Diplomate of the American Academy of Dental Sleep medicine. Dr. Schlott can be reached at wschlott@wschlott.com.

DentalSleepPractice.com

41

NUTRITION Protein Protein provides the building blocks for the body. Protein is needed for the body to grow, repair, and maintain itself. Protein is usually ingested as meat, but can be obtained from dairy products and some plant sources. Protein contains 4 calories per gram, but it takes one calorie to burn four calories of protein. It takes longer to digest protein than it does carbohydrates or fats.

Because of this and because protein reduces the levels of the hunger hormone Ghrelin and triggers the release of the digestive hormone CCK, which reduces hunger, proteins discourage overeating.6 Protein helps maintain lean muscle mass to boost metabolism and the amino acids from protein are essential for cellular health and building.

Fiber There are two kinds of fiber. Insoluble fiber consists of items the body cannot digest.

It does not absorb water. Insoluble fiber type helps speed food through the digestive tract and reduces the risk of constipation and hemorrhoids. The second type of fiber is soluble fiber. A by-product of complex carbohydrates, soluble fiber attracts water and becomes a gel like substance that swells. This

Carbohydrates, fats, protein, and fiber are all necessary for a proper diet.

42 DSP | Fall 2016

slows digestion to increase satiety. It also helps modulate blood glucose levels and lowers cholesterol. Inulin, a type of soluble fiber, promotes the growth of gut bacteria that improves bowel function and improves absorption of vitamins and nutrients. It also decreases the body’s ability to manufacture certain kinds of fat.7

E&M Most overweight people are judged by their body mass index.8 While this can be appropriate, some are labeled as overweight even though they may be a specimen of perfect health. Muscle weighs more than fat.

Hence, a muscular person could be marked as overweight even though they are healthier than most. Perhaps a better method is to calculate the waist to height ratio. The waist circumference measurement should be less than half of a person’s height. The waist measurement should be taken about an inch above the belly button.9 If the measurement is greater than one half of the height, the individual is at a greater risk for type 2 diabetes, high blood pressure, heart disease, and sleep apnea.

If food metabolism is understood, it becomes easy for the dentist to counsel patients about weight loss. Many nutritionists maintain that weight loss is 90% diet and 10% exercise. To burn the calories provided by eating a cupcake, it would require heavy exercise for over an hour. Nonetheless, exercise is important for a variety of reasons because among other things it can increase energy and stamina, create better moods, reduced stress, enhance memory, lower blood pressure, and improve sleep.

A moderately active person should attempt to achieve 6000 steps per day, with a goal of 10,000 steps per day as measured by a pedometer.10 Pedometers may be purchased at sporting good stores or as a phone app. Instead of attempting to exercise to a lean body, the main goal of weight loss should be to limit caloric intake. To maintain body weight, caloric intake should be about 1416 calories per pound of body weight for men, and 12-14 per pound of body weight for women. To lose weight, caloric intake should be less.11 To find the ideal calories

NUTRITION for an individual, caloric calculators found on the web can be useful.

The best way to lose weight is to eat the right foods. Generally, most people eat too many carbohydrates. Limiting their intake goes a long way towards healthier living.

Avoiding carbohydrates that have a high glycemic index is encouraged. Carbohydrates should comprise about 45% of one’s total calories. Protein should total 30-35% and fat 25-30% of the diet.

One of the bigger secrets to weight loss is to eat 5-6 meals per day. The three “main meals” should be eaten at “normal times”. About 2.5 hours after a meal, a snack should be consumed. Since proteins tend to mute hunger, the snack should contain protein. Many feel that at least 15-20 grams of protein should be eaten at the snack. This helps avoid gorging at the main meal. Simple carbohydrates as snacks should be avoided. An example of an good snack would be a piece of turkey wrapped in cheese. Main meals should include complex carbohydrates, protein, and some fat.

Purchasing a book or using the web, the caloric value of the foods can be determined. The goal would be to consume fewer calories than required for weight maintenance. With practice an individual can be proficient at estimating their caloric intake.

Another secret of weight loss is to drink plenty of water. Many times dehydration is interpreted by the body as hunger. Drinking 50-60 oz. of water per day eliminates this.

Avoiding sodas, even diet sodas, and alcohol is wise. Simple sugar is a major ingredient of sodas. Artificial sweeteners in diet soda have been implicated with interfering with digestion and have not been shown to reduce weight. Alcoholic drinks amount to empty calories. “Many a dietician will tell you “For every drink you have, you have to subtract something else from your diet, or add another mile on the treadmill.” Another secret for weight loss is the lack of vitamin D. Where appropriate, Vitamin D supplements may help with weight loss.12 Others advocate avoiding foods made from wheat.

Wheat is usually refined and used in baked goods. These simple carbohydrates are often unnecessary calories with little nutri-

Generally, most people eat too many carbohydrates.

Limiting their intake goes a long way towards healthier living.

It’s Here!!

Wear it. Trac it ®. DentiTrac ® DentiTrac is now available in the USA for use with select appliances.

For more information call 888-462-4841 x218

www.braebon.com @braebon

DentalSleepPractice.com

43

NUTRITION tional value. Losing weight and maintaining weight loss is simple with a little knowledge and common sense.

In the dental sleep office, weight counseling can be beneficial. If the dentist is pushed for time, an auxiliary can be trained to as1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

44 DSP | Fall 2016

sist patients. Remember, “People with severe sleep apnea who lost the recommended amount of weight were three times more likely to experience a complete remission of sleep apnea symptoms compared to people who didn’t lose weight.”13

Diabetes Solution, Richard Bernstein, MD, Little, Brown and Company 1997 The End of Diabetes, Joel Fuhrman, MD Little Brown and Company 2003 Biochemistry The Molecular Basis for Life, Trudy Mckee, James Mckee, Oxford Press 2013 Glycemic Index, Glycemic Index Foundation, www.gisymbol.com/aboutglycemic-index Lean for Life Cynthia Stamper Graff, Reginald Allouche MD. Harlequin Enterprises 2014 Hormones of the Gut users.rcn.com/jkimballimaultranet./BiologyPages/g/guthormones How Fiber Helps Your Digestive Health, Lisa Fields, David Kiefer MD, WebMD 2015 Body Mass Index Medline Plus, US National Library of Medicine Lean For Life, Cynthia Stamper Graff, Reginals Allouche MD, Harlequin Enterprises 2014 Wen, Chi Pang, et al, Minimum Amount of Physical Activity for Reduced Mortality and Extended Life Expectancy: A Prospective Cohort Study. The Lancet 378 (9798): 1244-53 Erin Coleman RE, LD, The Average Calorie Intake By a Human Versus the Recommendation, Demand Media Tremblay, Angelo, Jo-Anne Gilbert “Human Obesity: Is Insufficient Calcium/Dairy Intake Part of the Proble?” Jurnal of American College of Nutrition 30 (5Suppl 1):449S-453S Henri Tuomilehto, Et al The Impact of Weight Reduction in the Prevention of the Progression Of Obstructive Sleep Apnea: An Explanatory Analysis of a 5-Year Observational Follow-up Trial, Sleep Medicine, 2014: DOI: 10.106/j.Sleep.2013.11.786

PRODUCTspotlight

eyeCAD-connect®, the Heads-up Display for digital dentistry

by Sven Holtorf, DDS

30

years ago, with the introduction of digital scanning, a new window was opened for dentistry. Since then, the design and handling of the scanning units have gotten smaller, faster and more accurate, but the way they are used hasn’t changed significantly. The dentist scans the patient’s teeth and checks the monitor at the same time for the correct scanning outcome. This requires a constant change of the dentist’s posture and creates non-optimal ergonomic movements.

We are by nature comfortable with keeping an eye on what we are doing with our hands. Scanners generally require us to watch the screen for scan results while manipulating the device in the mouth. If the patient presents with challenges, (e.g. irregular teeth, reduced intraoral access) the need to turn our heads towards the screen while moving the hands can lead the operator to feel inept and the patient to a less-than-optimum experience.

Related problems are known in automotive production or aeronautical engineering in which the industrial cooperation between human beings and machines is vital – for this the solution is the ‘Heads-up Display.’ The important data about the task at hand and relevant measurements (automotive production) or information about speed, altitude, course, etc. (in aeronautical engineering) are projected into the heads-up display so that the wearer has the information directly in his or her field of vision and can concentrate on the task at hand. Recently, heads-up display is entering the world of medicine in surgery, where the doctor can monitor patient data while operating.

This principle is the basis for eyeCADconnect®, implemented into digital dentistry and first launched in March of 2015 at the IDS (International Dentistry Show) in Cologne, Germany. The scanned images DentalSleepPractice.com

45

PRODUCTspotlight

While performing the scan the practitioner can see both the scan screen and the patient at the same time.

are transferred in real time onto the display device so the hand/eye coordination of the operator improves significantly. The risk of inadvertent, uncomfortable contact with the patient while looking away is eliminated.

While performing the scan the practitioner can see both the scan screen and the patient at the same time. The ‘screen size’ of the scan image is adjustable, according to his or her needs, right in their field of vision.

Video glasses have been available for years, enabling dental patients to enjoy movies and other content as a distraction from the dental appointment. These are universally opaque, bulky, and completely different from the Epson Moverio BT-200, an advanced imaging system commercially available. What was missing was the ability to connect the scanner in real time, so Dr. Holtorf developed the eyeCAD-connect® software to take advantage of this advanced video system. Using a nano router to create a tiny local network, there is no interaction with vulnerable and unreliable wireless networks or slow Bluetooth connections.

This innovative German dentist wanted to stay in contact with his patients during

the appointments, cut the patient’s time not only in the dentist chair but also their time waiting for their new milled dental restorations. Other benefits include improved workflow and overall quality of the scans.

Patients can even wear the glasses to see how their crowns, inlays or especially orthodontic plans are being created in the software. For full arch study models and 3D bite records for sleep appliances, the patient can see their teeth appear on screen and get a nice visual representation of the forward jaw position chosen as a starting place to open their airway.

The glasses run on an Android system and come with all consumer apps (camera, Bluetooth, GPS, WiFi, etc.) They can be used outside the office for remotely connecting to any screen. The integrated software provides a secure connection between the scanning unit and the smart glasses using the nano router. By creating its own WiFi network around the unit, sensitive patient data stays in the office -no outside internet connection is needed. The glasses and the nano router operate wirelessly for maximum freedom of positioning the scanning unit and ease of movement for the dentist and patient. eyeCAD-connect® can be used for any PC-based intraoral scanner. There are also international market versions.

Clinician feedback has reported improved scan times, better patient experience and more comfortable use, leading to a faster integration of digital impressions in the daily practice. Delegating this task to trained team members enhances their contribution to office goals. This improves the return on investment for the technology.

Visit http://eyecad-connect.de for more information.

Sven Holtorf, DDS, graduated 1992 with a Doctor of Dental Surgery from Christian Albrechts University in Kiel, Germany. Since 1992, he is a resident doctor in Bad Segeberg with his own practice. Since 2003, he has been an avid CEREC user. In 2008, he graduated with a Master of Science in Oral Implantology from Steinbeiss University, Berlin. In 2014, he became a Certified Trainer for the DGCZ – Deutsche Gesellschaft für computergestützte Zahnheilkunde (German Association for computerized dentistry) and ISCD (International Society for Computerized Dentistry). He is a member of the CEREC Mentorship program and an international CEREC Advocate with lectures and continuing education in Germany and Europe in order to spread new dentistry innovations including new techniques and technology. Also in 2014, he founded the company iDent in order to promote continuous education. In 2015, he developed eyeCAD-connect – the head-up display for intraoral scanners.

46 DSP | Fall 2016

PRACTICEmanagement

5

Things Top DSM Practices Do

by Autumn Bodily, RDA

Y

ou bought the gym membership. It was on special and you were all amped up from the motivational speaker touting “extreme fitness and taking control of your life.”

But like so many things in life, it ended up just a little plastic piece of guilt on your keychain. But seriously, how do some people do it?! How is it we buy the same system as that guy and his practice grows and grows? Why does his staff seem so “on board” with making new things work and others’ seem to be sabotaging themselves from the inside out? In this edition we thought we’d take a look at the 5 things successful practices do to treat OSA. 1. They screen EVERYONE.

You’ve heard it before, “we screen all of our adult patients.” These practices hand out screenings like Ez Sleep’s Sleep Health Questionnaire or the Epworth to every patient.

This is a matter of course; just like updating the health history. However, far too many practices call me up and ask the best way

48 DSP | Fall 2016

to approach and screen the obese patient, or the man with the diminished chin. I get my answer from those successful practices, “We screen everyone.” Patients in the waiting room are always thumbing through magazines or fiddling with their phones. Why not give them something meaningful to read?

It’s amazing how often a patient will approach the dentist saying they were reading the symptoms and risk factors of obstructive sleep apnea and ask if maybe they should be tested.

2. The dentist connects with the patient.

The difference between a dentist and a successful dentist is sometimes referred to as chairside manner. Your patients come and sit in your chair. Despite whatever is going on in their lives, they have made their health and well-being a priority. Successful practices understand that in many cases, their patients have never even heard of Obstructive Sleep Apnea. They’ve certainly never imag-

Test. Trial. Treat.

Appliance Efficacy from Trial to Treatment

Fitting Your Custom Device Just Got Easier TEST Assess your patient’s sleep health condition using our patient-friendly, convenient, in-home testing device & easily identify qualified Apnea Guard® patients

TRIAL Improve your custom appliance outcome, reduce chair time and provide immediate therapeutic benefits by using Ez Sleep & Apnea Guard® together

TREAT Easily and quickly transfer settings from Apnea Guard® directly to your custom appliance & successfully continue your patient’s therapy

Improves Outcomes of a Custom Appliance

Details

Apnea Guard

Conventional

% with a 50% AHI reduction (n)

83% (20)

79% (22)

Days to successful outcome (n)

34 ± 7.6

136 ± 53.1 Apnea Guard, designed and manufactured by: Advanced Brain Monitoring, Inc. www.AdvancedBrainMonitoring.com U.S. and Intl Patents and Patents Pending

Contact us at: 888-240-7735 or visit: ezsleeptest.com

1. Treatment Efficacy Using a Trial Oral Appliance to Determine the Optimal Jaw Forward Position for a Custom Appliance. Morgan T, Meyers A, Melzer V, Levendowski D. Sleep 2014; 37:A361

PRACTICEmanagement ined it could be something that affects them.

The dentist is there to answer a few questions about OSA and dispel their fears. After all, he isn’t even sure if his patient HAS OSA. “We’ll cross that bridge when we get to it. Let’s first have you tested by a top notch Home Sleep Testing company like Ez Sleep. Once we get the results we’ll have something to talk about.”

3. It takes a village.

You want patients to ask “Should I be tested?”

I hear it all the time, “I’d be nowhere without my amazing staff.” This one orders, this one is a gem on the phones, this one can soothe even the most fearful patient.

The person who can take a patient’s money and still laugh with them like they were high school buddies is a rare personality. That’s why they man your front desk. The most successful practices know when Mr. Smith’s next cleaning is, when Mrs. Barnes’ RCT is ready for a crown, and how old her grandson will be.

These highly organized, ever-smiling front desk personnel are geniuses when it comes to scheduling a follow up consultation for the patient at risk for OSA. Yes, this consultation is 3-4 weeks out. However, that patient is far more likely to accept the testing from Ez Sleep, take the test the night they receive it, and ship it back right away.

After all, they want to know the results too!

According to reception here at Ez Sleep, we get upwards of 8-10 patient calls per week asking for their results. We assure them their results were sent to their dentist weeks ago.

Successful practices make that call far before their patient can call us.

Autumn Bodily, RDA, is a writer, a twenty year veteran of dentistry, and Ez Sleep’s Director of Education and Training. She knows a good Oxford comma when she sees one.

50 DSP | Fall 2016

4. They introduce partners.

A memorable introduction can go a long, long way. I love seeing a new patient walk into an office and be introduced to their hygienist, the treatment coordinator, the assistants, even the scrub tech. They get to see how a well-oiled machine runs. I know patients who want to see which lab the practice works with. In every successful OSA treatment case I can recall, the patient was introduced to us as Ez Sleep, their home sleep testing diagnostic company. When they see their trusted dentist trusting us…well, you see the pattern. This way, when an Ez Sleep scheduler calls to verify the shipping of their home testing device, the patient is confident they are still in good hands.

5. They can’t leave well enough alone.

When doing a root canal do you just remove the nerve and say to yourself, “yeah, I’m sure I got it all.” Umm. No. Proof, right?

You want empirical evidence to show your skill and competency as the professional you are. Same goes for sleep testing. You screened the patient and they showed risks. You prescribed a sleep test, told them the necessity of their cooperation and they smoothly took the Ez Sleep Home Test. You got the results from the Board Certified Sleep Physician and promptly shared them with your curious patient. You fitted them for an oral appliance and their symptoms have disappeared. Now, here’s what sets you apart: successful practices don’t stop there. They efficacy test their OAT patients. They show, without a shadow of a doubt, that this patient’s life has been ever changed. Consequently, that patient is now a lifetime wearer of the oral appliance to treat their sleep apnea. All because you went the extra mile.

Practices that are in this for the long haul have established themselves as strongholds in their community. More and more people are looking to their dentist for the treatment of snoring and they don’t even realize how their health is being improved. But we do.

We’re just like you. We want to screen and test every person showing risk. The more we expose this epidemic of obstructive sleep apnea, the healthier and safer our communities will be. Ez Sleep raises a tiny little key fob to the successful practices we work with. We may not run into each other at the gym, but we all have to sleep sometime.

PRACTICEmanagement

Your Sleep Ambassador is the Difference

by Dr. Gy Yatros

I

have worked with hundreds of dental practices over the past several years, providing education and training about how to effectively implement efficient dental sleep medicine production. There is one glaring difference between the practices that attain success and those that flounder. It doesn’t have anything to do with device titration, side-effect mitigation, or the dentist’s height. That one glaring difference is the existence of a DENTAL SLEEP AMBASSADOR in the practice. Call them what you will; ambassador, manager, guru, quarterback, spearhead. It doesn’t matter. What does matter is that this person is accountable for the sleep portion of your practice.

So who is this person? What are their responsibilities and what traits should they possess?

• Manages all aspects of your dental sleep production. Will be intimately familiar with the patient workflow.

• Has to be responsible, accountable, organized, AND they have to be granted the autonomy and authority to make decisions.

• Charged with training & ensuring protocols are in place AND being followed.

• Must be able to delegate required responsibilities.

• Possess critical thinking abilities, problem solving skills, drive, ambition, and a desire to continually learn.

To grow dental sleep production, you have to have the right people to manage the complexities involved.

Dr. Juliet Bulnes

Dr. Gy Yatros has been practicing dental sleep medicine for over a dozen years and is a well-respected international lecturer in the field of sleep-disordered breathing and dental sleep medicine. He has offices in Bradenton, Sarasota and Tampa, Florida devoted exclusively to the treatment of sleep disordered breathing. He is a Diplomate of the American Board of Dental Sleep Medicine (ABDSM) and is an Affiliate Assistant Professor of the Department of Internal Medicine with the University of South Florida, College of Medicine. He is a Co-Founder of the Dental Sleep Solutions system.

52 DSP | Fall 2016

A Sleep Ambassador will help you establish a better working relationship with other healthcare providers because they’ll be your practice’s primary contact. They will garner a greater understanding of the entire process and be able to discuss the results of a sleep test and confidently articulate to patients the financial aspect of oral appliance therapy. They will be the go-to person for your patients when they have questions and for your staff as well. If your Sleep Ambassador is savvy enough, they may even be able to perform some marketing duties such as lunch and learns or health fair presentations.

After floundering with two or three devices per month, one of our DS3 Members, Dr. Juliet Bulnes of Tampa, FL made what she refers to as a “leap of faith” and hired Stephanie, her part-time Dental Sleep Coordinator, aka Sleep Ambassador. “I hired Stephanie part-time and within two weeks, we changed that to full-time. To grow dental sleep production, you have to have the right people to manage the complexities involved”, says Dr. Bulnes. She also commented, “It was so tough for my team to juggle dental sleep while also ensuring their other jobs were done properly. Since joining us a year ago, Stephanie and my assistant, Jill, have been the driving forces behind our growth to an average of 10 devices per month. This has also enabled the rest of the team to focus on their jobs which makes everyone more productive. I’ve crunched the numbers and this change has ensured that Stephanie has paid for herself over and over again. It’s been tremendous and we’re just getting started.”

Identifying a team member to spearhead the DSM aspect of your practice will ensure a much smoother implementation process. The Sleep Ambassador can be an assistant, a front desk person, or a new hire BUT this has to be their primary focus. Your investment in this person will pay long-term dividends for you, your patients, and your practice.

CLINICALfocus

Maxillofacial-Mandibular Advancement and Oral Appliance Therapy Creating A Pathway To Successful Treat

by Clark O. Taylor, MD, DDS

C

hoosing the appropriate sleep apnea treatment for your patients depends on a number of factors, including the cause and severity of their condition, their medical history, and their personal preferences. Understanding when to utilize an oral appliance or when to explore the option of maxillofacial-mandibular advancement (MMA) surgery is vital to your practice and to the health of your patients.

Our Oral Appliance Protocol

MMA surgery has a much higher success rate than other sleep apnea surgeries, including UPPP.

54 DSP | Fall 2016

An oral appliance may be an ideal solution for patients with mild to moderate obstructive sleep apnea, especially those who do not need to use or do not wish to use a CPAP device. However, it is important to approach oral appliance use deliberately, so as to best understand its effectiveness with each patient. We follow this protocol: • The patient undergoes an attended sleep study to determine the diagnosis and apnea-hypopnea index (AHI). If the patient has an AHI of 15 or under and otherwise seems like a good candidate for oral appliance therapy, that treatment option is pursued.

• The patient undergoes a 3D airway scan.

This scan, which is done before the appliance is made as well as after the appliance is made, correlates the sleep study findings and analyzes the anatomical effects of the appliance. The fit is assessed by noting the position of the condyles with respect to the articular eminence.

The goal is to keep them in as normal alignment as possible. The airway volume and anatomy is evaluated with and without the appliance. This information is combined with the home study and clinical parameters to assess the effectiveness of appliance therapy.

• An oral appliance is fabricated with the assistance of an experienced dentist.

Dr. Clark Taylor with a patient

• The patient participates in three home sleep studies: two without the appliance and one while using the appliance. These three sleep studies help determine the effectiveness of the appliance. The appliance may need to be altered or another type of treatment may need to be pursued if the patient continues to have mild to moderate sleep apnea symptoms and their AHI remains elevated. The first two nights are utilized to establish a baseline, as there is some inherent disruption of sleep from simply using the apparatus. It is not unusual to find that the first night is the most severe with some stabilization during the second night. Hopefully, the third night with the oral appliance will give a true assessment with minimum disruption from the testing apparatus.

Maxillofacial-Mandibular Advancement for OSA

For patients with moderate to severe obstructive sleep apnea – and for those who are not helped by oral appliances, maxillofacial-mandibular advancement surgery, also known as bimaxillary advancement surgery, may be the best solution. This OSA surgery pulls both the upper and lower jaw forward, opening the airway, and increases the rigidity of the air column, making it easier for patients to breathe at night.

MMA surgery is an ideal option for symptomatic patients with an AHI above 20 and who have not responded well to other forms

CLINICALfocus of therapy such as oral appliances and CPAP. MMA surgery has a much higher success rate than other sleep apnea surgeries, including UPPP. MMA surgery should only be considered for patients who are in good health and who have a full understanding of the procedure and its likely results.

At Surgical Sleep Solutions, we have been performing MMA surgery for 25 years, and over the past 11 years have performed this procedure as an outpatient procedure.

During this time, we have had a success rate of above 90 percent with no unplanned hospital admissions. Our treatment model results in shorter recovery times and a result that often allows patients to forego the use of their CPAP device.

In some cases, patients with severe sleep apnea may still have an above-normal AHI after surgery. In this case, an oral appliance is an excellent way to further treat symptoms after the MMA procedure. This is especially true if the patient chose the surgery because they had difficulty with CPAP therapy (for any number of reasons).

The Financial Aspects of OSA Surgery

Despite its many advantages for some patients, Maxillofacial-mandibular advancement surgery is understandably a more expensive treatment and solution than oral appliances and some other types of therapies.

While the health and quality of life of the patient is of first importance, patients are understandably concerned with whether they can afford the procedure and which of the procedure’s costs are covered by their health insurance policy. We have been successful in obtaining insurance coverage for the majority of our patients. Originally, our outpatient treatment model, which takes place in our private facility, was developed so that the patient could benefit from having a single surgical team comprised of experts on the procedure; an anesthesiologist specifically trained for the operation; and one-on-one, minute-to-minute nursing care following the operation. But not only did all three of these aspects greatly improve operating times, blood loss, postoperative pain thresholds, it also dramatically reduced the cost of the procedure. In addition our patients returned to light normal activity and a soft chewing diet in 7-10 days. A retrospective evaluation of the costs associated with outpatient delivery

revealed that in most cases, the costs were reduced by more than half over having the procedure done in a hospital. In most cases, costs were reduced by more than half.

The combination of factors listed above has made the utilization of this procedure much We have had a success rate more acceptable to the average of above 90 percent with patient. It is because of these factors that it is our procedure no unplanned hospital of first choice in the treatment of moderate to severe obstruc- admissions. tive sleep apnea in patients who wish to eliminate CPAP therapy for any number of reasons.

Making the Right Choice for Patients

When seeking the best route to health for each patient, it is imperative to take the following steps: • Understand the patient’s medical history.

• Learn about the patient’s sleep apnea presentation and severity.

• Learn about the patient’s sleep apnea treatment history.

• Start with less invasive and expensive treatments, such as oral appliances (for less severe cases).

• Consider MMA surgery in cases of moderate to severe OSA and in cases where CPAP use is not possible or not preferred.

• Analyze the effectiveness of your chosen treatment and act accordingly. Consider the use of oral appliances if mild symptoms persist following surgery.

Clark O. Taylor, BA, MD, DDS, has been practicing medicine and performing surgery for three decades and is the Founder and Director of Surgical Sleep Solutions. He received his bachelor’s degree from Wichita State University, his Doctor of Dental Surgery (DDS) from The University of Missouri, Kansas City, and his Doctor of Medicine (MD) from Northeastern Ohio Universities College of Medicine.

Dr. Taylor has been actively involved with the teaching of residents and postgraduate training fellows in the field of maxillofacial surgery. Throughout the course of his career, Dr. Taylor has maintained active academic appointments at major teaching hospitals where he provides training and continuing education for a variety of surgical specialties. He also treats patients and continues to educate physicians through his practices in Missoula, Montana, and Palm Desert, California.

DentalSleepPractice.com

55

LEGALledger

Short Stuff

by Ken Berley DDS, JD, DABDSM

A

s I write this article, I have just returned from the AADSM meeting. I enjoyed reconnecting with old friends and making many new ones. However, it was challenging to find adequate time to answer all the questions which came rapid fire from every direction. Not that I mind answering questions, obviously that is not the case or I would not be writing this column. However, I admit it, sometimes I do get tired of answering the same questions over and over. Since, there does seem to be recurring themes, I thought that I would attempt to cover several topics that do not warrant a full article devoted to them. I apologize in advance for the lack of continuity on display. However, using this approach I will attempt to cover a lot of territory in this one article.

56 DSP | Fall 2016

Terminating Treatment

“What should I do if a patient leaves my practice in the middle of treatment?”

A dentist is obligated to discuss with a patient the treatment being recommended and any reasonable alternatives that exist. That disclosure allows the patient to make an informed decision concerning the treatment that he or she will receive. This information sharing is all part of informed consent. That same philosophy should be followed if a patient decides to abandon a course of treatment that has already begun (or refuses to accept any treatment). In such cases, the dentist should provide the patient with a description of the potential risks and consequences of failing to treat OSA. This disclosure should include any reasonable risks to the patient’s health including, high blood pressure, stroke, heart attack, demen-

LEGALledger tia, motor vehicle accidents, etc. Once the patient is informed of the seriousness of untreated OSA, the patient has the legal right to refuse treatment or discontinue treatment at any time. Where treatment is refused or discontinued, the dentist should make sure that the patient’s record reflects the advice given, including any health warnings or risks that were relayed to the patient. The record should reflect that the patient was fully informed of the potential risks of refusing treatment and therefore made an “informed refusal” of treatment. For OSA patients, the dentist is further obligated to make sure that the patient is referred back to his or her sleep physician or PCP for alternative care.

“What do I do if the patient refuses to follow protocol?”

This question typically arises in the context of patients refusing to go for a final PSG or complying with recall instructions or appointments. AADSM Practice Parameters 2006 states: 3.4.2 To ensure satisfactory therapeutic benefit from OAs, patients with OSA should undergo polysomnography or an attended cardiorespiratory (Type 3) sleep study with the oral appliance in place after final adjustments of fit have been performed.

I think we all agree, it is best if our patients return to the sleep lab after in-office titration for a final PSG where the MAD is further titrated for maximum medical improvement. Unfortunately, many patients do not enjoy the friendly confines of the local sleep lab and are resistant to comply with this recommendation. As stated previously, the patient should be fully informed of the protocol for the treatment of OSA utilizing Oral Appliance Therapy. The patient should be made aware of the medical and other benefits of a final in-lab titration to achieve the best results of MAD therapy. However, if after being fully informed of the risks and rewards associated with refusing to attend a final in-lab PSG, you should then document the patient’s informed refusal. You should list the risks and benefits which were shared with the patient before refusal. This list should include the fact that the patient’s MAD may not be adequately titrated due to the patient’s refusal to follow protocol. In my office, I involve the referring physician. I send a letter

informing the physician of the refusal and I ask the sleep physician to send the patient a letter or call the patient and explain the need for a final PSG. Rarely do I have a patient stubbornly refuse to comply after the benefits are adequately explained.

3.4.3 Patients with OSA who are treated with oral appliances should return for follow-up visits with the dental specialist.

Once optimal fit is obtained and efficacy shown, dental specialist follow-up at every 6 month is recommended for the first year, and at least annually thereafter.

The purpose of the follow up is to monitor patient adherence, evaluate device deterioration or maladjustment, evaluate the health of the oral structures and integrity of the occlusion, and assess the patient for signs and symptoms ... After the patient of worsening OSA. I personally take the recall of my is fully informed, they patients very seriously! It is amazing have a legal right of how frequently at a recall appointment I discover that the patient is no longer self-determination. completely compliant with my treatment. Yet, we struggle to get our patients to comply with recall. When a patient does not return for recall, we make at least three different attempts to reappoint that patient. We go to great lengths to explain the necessity of recall to insure the fit, function and effectiveness of our treatment. However, after the patient is fully informed, they have a legal right of self- determination. The patient can refuse your attempts at recall. These attempts to appoint the patient must be well documented with the response of the patient included in your notes. After the patient is fully informed and the “informed refusal” is documented in your records, send the patient’s sleep physi-

Dr. Ken Berley is a practicing general dentist with over 30 years of private practice experience focusing on complex reconstruction and 20 years of experience as an attorney licensed to practice law in Arkansas and Texas. He has extensive experience as a litigator and was a full partner in Travis, Borland and Berley, Attorneys’ at Law before moving to Northwest Arkansas. Dr. Berley is a Diplomate of the American Sleep and Breathing Academy and a Diplomate for the ABDSM. He lectures in the area of sleep medicine risk management. He has provided TMD treatment for many years and has incorporated Sleep Medicine in his office for the last 3 years.

DentalSleepPractice.com

57

LEGALledger cian a letter explaining that the patient has removed himself from recare. Be sure to send the patient a copy of the letter.

Our office makes final PSG’s and recalls such a big deal we rarely have a patient refuse. This past year I only had one patient refuse a final PSG.

HST Ownership

I have been involved in numerous hearings before different state boards and if discipline or sanctions are imposed, it never involves the loss of your home.

The Luco Hybrid OSA Appliance Sleeping in Complete Comfort

The first FDA cleared treatment for sleep bruxism and associated tension/migraine headaches K160477

K130797

www.lucohybridosa.com Available through: Apex Dental Sleep Laboratory (619) 724 6041

58 DSP | Fall 2016

“Will I lose my house if I own HST equipment?”

The short answer is NO! Despite what you may have experienced at the AADSM, I have been involved in numerous hearings before different state boards and if discipline or sanctions are imposed, it never involves the loss of your home. First, if a treatment or condition falls broadly within the definition of the practice of dentistry, there is a legal presumption that you can explore any means within your expertise to treat that condition. As I am sure you are aware, very few state dental boards have taken up the subject of HST. Therefore where HST usage has NOT been addressed, you have a legal right to assume that HST usage is not illegal until such time that your state board determines otherwise. However, if you practice in Oregon, Georgia, Connecticut, New Jersey, New Hampshire, Alabama or Virginia, your state boards have taken some action or published an opinion on the treatment of OSA or HST usage. The next question is how are you using your HST equipment? In my office I utilize both HST and High Resolution Pulse Oximetry to screen and titrate. I do not order diagnostic home sleep testing in my office, nor do I employ a remote Sleep Physician who has not seen the patient to provide a diagnosis. Not because it is illegal for me to do that, but because it would make the sleep physicians that I work with mad. Additionally, I would be accepting all the risks of treatment. Personally, I want to share liability with other healthcare providers, therefore, I would never treat an OSA patient without the involvement of a physician. When I screen patients for OSA, I always refer those patients to a local sleep physician. This allows for a good working relationship with the Sleep Physicians in my area. I refer to the local sleep physicians and they reciprocate.

Yes, this arrangement is a “quid pro quo” but it is not illegal. If I refer patients to local sleep physicians for diagnosis and treatment, I then routinely receive referrals of CPAP in-

LEGALledger tolerant patients for OAT. If I were using HST for diagnosis, it would jeopardize this relationship. I’m not going there!!!

Now let’s briefly discuss the new Georgia Dental Board ruling. It states: Depending upon the diagnosis of the type and severity, one possible treatment option for obstructive apnea is the use of oral appliances. The design, fitting and use of oral appliances and the maintenance of oral health related to the appliance falls within the scope of practice of dentistry. The continuing evaluation of a person’s sleep apnea, the effects of the oral appliance on the apnea, and the need for, and type of, alternative treatment do not fall within the scope of dentistry.

Therefore the prescribing of sleep apnea appliances does not fall within the scope of the practice of dentistry. It is the position of the Board that a dentist may not order a sleep study. Home sleep studies should only be ordered and interpreted by a licensed physician. Therefore, only under the orders of a physician should a dentist fabricate a sleep appliance for the designated patient and conduct only those tasks permitted under O.O.G.A. Title 43. Chapter 11.

When you look at the Georgia Rule in its entirety, a number of things jump out. First it attempts to define not only the scope of practice for dentists, but also the scope of practice for physicians. This is an obvious overreach.

With that aside, the one thing that is certainly

When I screen patients for OSA, I always refer those patients to a local sleep physician. This allows for a good working relationship with the Sleep Physicians in my area.

clear is that a dentist cannot provide Home Sleep Testing in his office which is read by a remote Sleep Physician and then fabricate a MAD without any other involvement by a physician. From a risk management strategy, if any readers are routinely employing this type of model where they are performing HST and providing OAT without a prescription from a physician, you are putting yourself in a position of significant risk. DON’T DO THAT! With that said, this paragraph is very poorly drafted and creates a great deal of uncertainty.

If I read this statute literally, which attorneys are taught to do, it seems to state that it is not illegal to utilize HST in the state of Georgia in some circumstances. This statute states that a dentist cannot order a sleep study utilizing HST. By definition a sleep study is for the diagnosis of OSA and not for patient screening or oral appliance titration. So the question is: “Can a dentist in Georgia utilize HST equipment for the titration of oral appliances?” My answer would be YES. When oral appliances are titrated, most dentists do not send this data to a sleep physician for scoring and the data is not being utilized to diagnose the existence or severity OSA. Computer scoring is typically utilized, therefore, I would argue that a titration study does not meet the definition of a “sleep study”. If the board wanted to ban ALL usage of HST that statute would have been simple to draft. The wording of this statute does not ban the ownership of HST equipment or the utilization of HST for titration of Oral appliances. The Georgia Board of Dental Examiners chose not to incorporate verbiage banning all HST ownership. This statute prohibits a dentist from ordering a diagnostic home sleep test only. In my opinion the verbiage of this poorly drafted statute certainly opens the door for legal interpretation and confusion.

As a side note, I personally feel that this statue would not withstand a legal “constitutional” challenge. Not because the board does not have the legal authority to limit the use of HST, it certainly does, but, this statute is so poorly written a Judge would likely throw it out as ambiguous.

Informed Consent

“Does consent have to be in writing?”

I am aware that some lecturers in Dental Sleep Medicine routinely declare in lectures that verbal informed consent is a breach of

60 DSP | Fall 2016

LEGALledger

The lack of a written consent greatly increases your risk of being sued!

The Largest Selection

Of Sleep Appliances in the USA...

and more!

Narval™ CC

EMA

UCLA Adjustable Herbst Slim Line

Lamberg™ SleepWell

$285.90

1-800-423-3270 www.SMLglobal.com 62 DSP | Fall 2016

the “standard of care”. That is a common misconception among healthcare providers. You should know the standard of care is determined by law not by the misinformed lecturers. Sadly as a result, there is still confusion in the area of informed consent.

Frequently, I am asked about whether “the law says that consent has to be in writing?”

The Law of informed consent has been settled for many decades. Under the Law, Informed Consent generally DOES NOT have to be written. Now before you go nuts, you need to be aware that each state has statutes and case law that list certain procedures where consent MUST be in writing. The types of medical procedures that are historically found in these state statutes are: procedures that could result in the sterilization of the patient; breast biopsies, in vitro fertilization, and HIV testing. All other medical procedures can be verbal. That is the LAW! However, you should be aware that in this day and time, juries expect consents to be in writing. While that is not the law, it certainly the perception of juries. Therefore, from a risk management prospective, consents should be in writing! It is my experience that if you do not have a written consent when a plaintiff’s attorney reviews your records, you will likely be sued! Most plaintiff’s attorneys do not know if you did anything wrong. They just know if the patient suffered a “bad” outcome and whether a written consent lists the “bad” outcome as a possibility. Therefore, it is not a breach of the standard of care for consent to be verbal, but the lack of a written consent makes it virtually impossible to prove what was discussed with the patient to obtain consent. In my legal opinion, the lack of a written consent greatly increases your risk of being sued!

E-codes

“Can I use an e-code to file medical insurance for this product?”

To be continued! I was asked by several vendors if it is legal to employ certain E-codes to file medical insurance for different products and have the dentists distribute that product. I hope to answer this question in the winter edition. There, I will discuss the products and the codes involved and let you know my thoughts. Stay tuned! More to come!

LINKEDIN

Excerpt from “Consensus on Verbal Skills that Help Build a Dental Sleep Medicine Practice”

by John Viviano, DDS, DABDSM

T

he LinkedIn Discussion Group, “SleepDisordersDentistry” has just completed an open discussion on “Verbal Skills” that help build a dental sleep medicine practice. The full consensus statement is available at the LinkedIn group.

What was asked

“Building a Dental Sleep Medicine Practice has proven to be both exceedingly rewarding and exceedingly difficult. Obstacles abound; physician resistance, re-imbursement resistance, misinformation about oral appliances, fear of side effects such as bite changes, the learning curve involved, etc.

Let’s share our personal experiences, tips, suggestions, and in particular, “Verbal Skills” that effectively deal with these barriers…”

What was said

Tony Soileau posted links to videos he created, directed at the layperson, to communicate sleep issues with patients. Kent Smith shared that he viewed these videos repeatedly to glean phrases that may come in handy in his practice.

Rob Suter feels that inadequate “Verbal Skills” is one of the primary reasons more patients don’t get diagnosed and treated.

“University of Chicago hospital used the Stop-Bang on 1,000 patients and tracked only 8% getting treatment! So 92% with high risk for OSA fell out of the sleep channel at one of our top Academic Hospitals.”

Rob insightfully suggested that if this is the success rate experienced in a top-tier Health Centre, as dentists we have to work that much harder to motivate to therapy. His company, OSA University, softens the term ‘Sleep Apnea’ to “Airway Health.”

“Instead of saying you could die of an MI or have a stroke, focus on things people really care about: Weight, Energy, Cognition, Skin Quality, etc. Those are the things people spend tons of money on and are motivated by.”

Rob shared: “Many DDS teams can’t handle sleep phone calls if they aren’t trained or experienced to collect key pain points and verbalize what OAT or PAP can do to relieve that pain point.”

Steve Carstensen joined in and provided something he learned at the Pride Institute many years ago.

“The first point is to learn what is the Chief Complaint. Nobody wants a “MAD”, they want to “Stop Snoring”, for example. This communication is not unique to medicine, it’s universal human connectivity. We must address others where their concerns lie. For patients, it is the symptoms. For our colleagues, it is a mixture of their commitment to improving their patients’ health and their business. When we take time to learn what other’s hot buttons are, we can shape our responses to keep them involved in the conversation. If a patient calls and says “I want to stop snoring’ and we talk about ‘AHI’, we’re not meeting them where they are. Doesn’t mean our clinical wisdom isn’t important, it just means we are not giving the encounter enough chance to be successful.

If our collaborating physicians perceive that we do care about them, their patient outcomes, and their desire to remain in the treatment loop (no matter

what their motivation for that is) then we have a better provider team. Better communication comes with focusing on the other person.”

Todd Morgan stressed the importance of a well-trained team and the “Hand Off” approach he uses in his office. Todd’s assistant acts much like a PA in the sense that they work-up the patient’s Chief Complaint (CC) and History before he sees them. The assistant will then “Hand-Off” the patient to Todd while reciting the CC, prior issues and History. Todd finds that this system saves time and the patients feel like they have been heard!

Kent and his team listen for the “M&M”, or “What Matters Most” to the patient. Kent places the patient’s M&M in the chart note to refer to when following up as the patient’s progress through therapy. The M&M is also passed on to the physician and the financial coordinator (if needed), so the patient is kept aware of why they actually made the appointment in the first place and how far they have come as therapy progresses.

Once again, I would like to thank all those clinicians that took the time to participate in this discussion, this consensus article is intended to provide guidance for those that are new to this area of practice and also to provide valuable insights for those of us that have been at this a while. I look forward to your participation in future SleepDisordersDentistry LinkedIn discussions.

John Viviano, DDS, DABDSM, obtained his credentials from the University of Toronto in 1983.

His clinic is accredited by the American Academy of Dental Sleep Medicine and is limited to providing conservative therapy for Sleep Disordered Breathing and Sleep Bruxism. A member of various sleep organizations, he is a Credentialed Diplomate of the American Board of Dental Sleep Medicine.

DentalSleepPractice.com

63

SLEEPdeeplyWAKErefreshed

CLUES Across 4. Sleep noisily 5. Ensuring a device is the correct size 6. Sleep study test to diagnose obstructive sleep apnea, abbr.

7. Thing referred to 8. Take steps 10. _____ advancement, MMA 11. One of five stages of sleep 14. It’s used to measure the severity of sleep apnea, abbr.

15. Condition that causes breathing to stop and start during sleep, abbr.

16. Sleep ____, aka polysomnography 18. Effective treatment for snoring and obstructive sleep, abbr.

19. Record of medical events 21. Concealed 24. Disorders characterized by abnormal respiratory patterns or insufficient ventilation during sleep, abbr.

25. Test to diagnose sleep disorders 26. Patient’s tag shows it 27. It can cause pain in the jaw joint, abbr.

28. Function 30. It’s often a major factor in sleep apnea conditions 31. It might be used to reduce the size of 30 across 32. It’s used for screening sleep apnea patients, goes with 18 down

Down 1. Rest 2. Passage that gets blocked during sleep apnea 3. How old a patient is 4. Street, for short 5. Hold in place 6. Appliance that can be effective for those with sleep disorders 9. Common treatment for sleep apnea cases 12. Sleep apnea _____ guard 13. Obesity is a _____ of sleep apnea in patients 16. ____ position- on the side is best for sleep apnea patients

For the solution, visit www.dentalsleeppractice.com/crossword.

64 DSP | Fall 2016

17. www.medmarkaz.com is one 18. See 32 across 20. It’s been used as an alternative treatment for patients that don’t adhere to the CPAP treatment 22. Overall term for dental treatment of sleep disorders, abbr.

23. Retain in place 28. Sleep disorder characterized by airway resistance to breathing during sleep 29. Steady, as in pressure 30. Mandibular advancement device, abbr.

FOR THE TREATMENT OF SNORING AND OBSTRUCTIVE SLEEP APNEA FDA Cleared

• Durable - made with clinically unbreakable Clear 450® • Retentive - no ball clasps required • Posterior Titration - for better patient comfort • Open anterior for better air flow • Only $305 - available with thermo-adaptive liner for $325 • Send George Gauge™ bite registration and models, impressions or scans • Only 5 Lab working days

Also available from Keller, dreamTAP® • Exterior hardware offers greater tongue space • Single point of adjustment prevents bilateral adjustments • Hardware made from nickel-free cobalt chromium • Only $385 • Send centric bite registration, maximum protrusive measurement and upper and lower models, impressions or scans • Only 3 lab working days

Call Today For Your Case Pick-Up!

800.325.3056

FREE

Shipping

160 Larkin Williams Industrial Ct. • Fenton, MO 63026 • 800.325.3056 • kellerlab.com

Diagnosis

Treatment Plan

TMD

Airway Analysis

Guided Implantology CERECÂŽ Integration

Dentsply Sirona 3D puts you in control Advanced technology that’s easy to use With a single 14-second scan, Dentsply Sirona 3D provides you with all the 3D images required to confidently diagnose and accomplish any procedure. With three models to choose from, each configurable with several software possibilities, Dentsply Sirona 3D provides you with a future-proof system with room for expansion as your practice needs grow.

Contact your Patterson Representative for more information.

Or call Dentsply Sirona directly 800.659.5977. sirona3D.com

Exclusive U.S. Distributor Extra-Oral Imaging Products